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THE TRUTH ABOUT 
TWILIGHT SLEEP 




Dr. Carl J. Gauss, who with Dr. Kronig, developed the 
Freiburg method of painless childbirth 



THE TRUTH 

ABOUT 

TWILIGHT SLEEP 




BY 

HANNA RION (Mrs. Frank Ver Beck) 

AUTHOR OF 

"Let's Make a Flower Garden," "The Smiling Road," 
"The Garden in the Wilderness," etc. 



NEW YORK 

McBRIDE, NAST & COMPANY 

1915 



Copyright, 1915, by 
McBride, Nast & Co. 






Published February, 1915 



VAIL-BALLOU COMPANY 
BINQHAMTON AND NEW YORK 



FEB 24 1315 

©CIA393725 
%0f 



FOREWORD 

Medical science has at last solved one of the great- 
est problems of humanity — the agony of women 
in childbirth — but perhaps you do not realize that 
this method, popularly known as " Twilight Sleep," 
is being successfully used in Russia, France, Austria- 
Hungary, Germany, Finland, Japan, The Argen- 
tine, and England, Scotland, and Ireland to-day, 
both in maternity hospitals and private practise. 
It is in the hope that the spreading of this fact may 
bring comfort to all mothers that I have written 
this book. 

I am not telling you anything from hearsay; I 
have spent six months in preparation for this work ; 
for three of those months I was in close contact 
with the maternity hospital of Freiburg, Germany, 
where over five thousand women have been pain- 
lessly delivered by this method; I have translated 
almost two hundred thousand words of foreign 
medical reports on the use of the two drugs — 
hyoscin (or scopolamin as it is known on the Con- 



FOREWORD 

tinent) and morphin — which produce Twilight 
Sleep. 

While a few of the early Continental reports are 
antagonistic and record failures, the British medical 
reports from the beginning are practically unani- 
mous records of success. In the desire to leave no 
stone unturned whereby I might inform myself, I 
have visited as many of the British physicians as 
I could, begging them to enlighten me further on 
this vastly important subject, and I can assure you 
that the method of " Painless Childbirth " is now an 
established institution in Great Britain. 

Though thousands of women have already been 
benefited by this humane treatment, yet there still 
remain thousands and thousands of other mothers 
who continue to suffer unrelieved agony at child- 
birth in utter ignorance that painless delivery is 
within their reach. 

How shall we let mothers know this fact? 

I know of but one way — for a mother, such as 
myself, to write to her fellow mothers telling them 
all she knows of the matter. The professional con- 
servatism of the medical body prohibits it giving 
general publicity to any scientific development of 
medicine. The physicians are absolutely in the 
right when they avoid anything which may seem 
like advertising, for we cannot but realize the un- 



FOREWORD 

dignified position of a Friedmann in his exploita- 
tion of a tuberculosis cure. 

The British doctors, for example, have been un- 
ostentatiously employing the method of Twilight 
Sleep since 1907; at various meetings of the medi- 
cal association papers have been read on the subject 
of painless childbirth and have afterward been 
printed in the medical journals, which are the only 
proper channel through which such facts should be 
published — according to medical etiquette. 

But what mother ever reads a medical journal? 
— unless, like myself, she is making exhaustive 
study of some subject which is only dealt with in 
such journals. The very audience, then, which is 
in crying need of information on this subject — the 
mothers themselves — are not reached and remain 
in ignorance of the great advance which medicine 
has made for their relief in their greatest hour of 
trial. 

It is true that the mothers who have been so for- 
tunate as to chance upon physicians employing" the 
method, have done all they could by telling others, 
thus spreading the blessing by word of mouth 
propaganda, but this is at best a slow process. 
Only by a book directly written to women can the 
great mother-public be reached. 

While among the Continental obstetricians a 



FOREWORD 

belief still exists that Twilight Sleep is best adapted 
to the hospital, the British doctors have proven that 
the method is entirely practical in private practise; 
this brings it also within the reach of mothers who 
prefer to have their babies in their own homes. 
Where it is employed in private practise, the doc- 
tors inform me, it is not at all necessary to keep 
the patient under constant supervision. 

In writing of the simplicity and advantages of 
the method in private practise, one physician says: 
" It is capable of saving the practitioner many a 
worrying day and weary night and the patient much 
exhausting restlessness." To quote again : " It is 
difficult to describe the attractions in private prac- 
tise of a method which relieves the patient's suffer- 
ing while it allows labor to progress regularly and 
which does not require the constant personal pres- 
ence of the medical practitioner, as the anesthesia 
with chloroform does." The fact that Twilight 
Sleep has been found practical in private practise 
by the British doctor proves not only the technical 
skill of the British practitioner, but it is also a guar- 
antee of the safety of the method. 

In one of the largest Scotch maternities, I was 
told it is now such a daily occurrence to give moth- 
ers scopolamin-morphin injections, it is taken as a 



FOREWORD 

matter of course and records are no longer even 
kept of these births. 

So you see I am not heralding a new thing; I 
am writing to you of a scientific method of child- 
birth which has stood all the tests of experimenta- 
tion and is now an accepted and perfected institu- 
tion in many countries. Let us hope that within 
a year the same may be said of Twilight Sleep in 
America. 



CONTENTS 

CHAPTER PAGE 

I The Question of Reducing the Pain of Child- 
birth i 

II The Mother's Experiences 20 

III My Visits to the British Doctors .... 47 

IV To Mothers 62 

V Gauss's First Publication on Twilight Sleep . 67 

VI The Famous Hocheisen-Gauss Controversy . 101 

VII Gauss's Published Reply to Hocheisen . . .126 

VIII Dr. Preller's Experience With the Dammer- 

schlaf 143 

IX Several German Reports and a Wonderful 

American Experiment 155 

X The Remarkable Reports of 1908 183 

XI The Singular Metamorphosis of Scopolamin 

in Surgery 205 

XII How Does Twilight Sleep Affect the Child? . 220 

XIII Reports From Hungary, The Argentine, Rus- 

sia, England and Germany 232 

XIV Gauss's Latest Address on Twilight Sleep . 249 

XV How the Variability of Scopolamin was Over- 
come 262 



CONTENTS 

CHAPTER PAGE 

XVI The Simplified Method Witnessed by the 

Visiting Physicians in the Summer of 1914 271 

XVII The American Physicians and Painless Child- 
birth 302 

XVIII The British Success With Twilight Sleep . 339 

XIX Conclusion 358 

Medical References 363 

Index 367 



THE ILLUSTRATIONS 



Dr. Carl J. Gauss Frontispiece 



First American child born in Freiburg . 
American boy also born in Freiburg . 
Two Twilight-Sleep babies .... 

Dr. Bernhardt Kronig 

Twilight-Sleep children of Herr Hensler 

Dr. Aschofr* 

Dr. Hoche 

Two of the first Twilight-Sleep children 
Prof. Walther Straub and his son 



FACING 
PAGE 

2 

2 

i6 v 

36' 

64 

102 
102 

158 
264 



THE TRUTH 
ABOUT TWILIGHT SLEEP 



The Question of Reducing the Pain of 
Childbirth 

AS far back as 1907 an American physician ' in 
writing of the method of Twilight Sleep said : 
" The dread of pain has been the great dread of the 
coming birth; until this discovery the ' pains of ma- 
ternity ' remained a horrid and incontestable truth, 
but these have vanished and the exhausting ordeal 
of motherhood is gone, to be seen no more." That 
last line is really the most remarkable message of 
comfort which has ever been sounded to women. 
Childbirth is the only physiological event of life 
which is accompanied by great suffering. 

Has the doctor, whose duty it is to mitigate pain, 
the right to interfere during the natural pangs of 

1 "The Hyoscin Sleep in Obstetric Practice," by Wood- 
bridge Hall Birchmore, M.D. Medical Record, Vol. 71, June, 
1907. 

I 



2 THE TRUTH ABOUT TWILIGHT SLEEP 

delivery? That is the question which has always 
faced the medical profession and which has never 
received from it a unanimous reply in the af- 
firmative. In the dim past we find that the Hindu 
tried to exorcise the pangs of motherhood by the 
vapor of charcoal, which when inhaled caused a 
stupefaction of the senses. Curiously enough, it 
has been found by an English doctor that this same 
primitive method of vapor of charcoal is employed 
to-day by one of the African tribes, while another 
tribe soothes the mother's pain by means of intoxi- 
cating beverages. 

Down through the centuries, while all so-called 
heathen races, inspired by that sympathy which 
runs like a thread of gold through all humanity, 
tried by sorcery and primitive devices to mitigate 
the sufferings of maternity, we Christians alone op- 
posed every effort made for a modification of what 
we called the "normal, physiological pains of 
birth." 

It was not until a certain historical birth took 
place at court that the solid wall of opposition 
was broken through — this event was in 1853 when 
Queen Victoria was painlessly delivered of a child 
under chloroform by Sir James Simpson. This 
royal birth caused this especial form of narcosis to 
be henceforth known as chloroform a la Reine. 




The first American child born in Freiburg. Mrs. Emmet 
of New York, her mother, was responsible for many 
other American mothers trying Twilight Sleep 




This American boy was also born in Freiburg at the 
Frauenklinic 



REDUCING THE PAIN OF CHILDBIRTH 3 

To write of chloroform to-day would be archaic 
— nay, absurd, so well known are its merits and 
demerits — yet when chloroform was first intro- 
duced there was an almost overwhelming prejudice 
against its use. Aside from the opposition of the 
clergy to its employment in childbirth (the argu- 
ment being that women had been condemned by 
divine command to bring forth in sorrow), it was 
furthermore opposed by the law, which declared the 
abrogation of consciousness illegal. 

As great a blessing as chloroform has become 
for the obliteration of consciousness during severe 
operations, it has not proven the ideal means for 
the relief of women in childbirth. In fact, none of 
the usual forms of inhalation narcosis can be used 
to extend over the entire period of birth without 
fear of producing serious disorders of the vital or- 
gans. If given in small non-poisonous doses, the 
effect is insufficient to produce any distinct relief. 
Moreover, care must be taken that an anesthetic 
does not interfere with the functions of the muscles 
on which everything in birth depends. 

Doctors have from time to time made experi- 
ments in childbirth with bromethyl, chlorethyl, ni- 
trous oxid (laughing gas), antipyrin, cocain, and 
the medullary narcosis (injections in the spinal 
cord), but none of these have proved to be entirely 



4 THE TRUTH ABOUT TWILIGHT SLEEP 

effective, and after various trials have generally 
been abandoned. In view of the long list of ex- 
periments and the doubtful success of various 
methods, it was a scientific event of far-reaching 
importance when von Steinbuchel of Gratz made his 
first experiments in childbirth with the combination 
of scopolamin (or hyoscin) and morphin. 

In 1905, Dr. Carl J. Gauss, of the Freiburg 
Frauenklinik, took up the study of scopolamin- 
morphin, and under the supervision of Geheimrath 
Dr. Bernhardt Kronig, he developed the method of 
painless childbirth which is now known throughout 
the Continent as " The Gauss Dammerschlaf." 

By slightly increasing von Steinbiichel's dose of 
the drugs, Gauss found that the patient remained in 
a state of clouded but not obliterated consciousness, 
and then he observed a most singular affection of 
the memory : events which had occurred before the 
patient had entered this state of clouded conscious- 
ness were perfectly recalled, while all impressions 
received while in this condition were entirely for- 
gotten. To express this peculiar state — which 
more closely resembled a waking than a sleeping 
one — Gauss coined the word " Dammerschlaf," 
which means a twilight sleep. 

It might be asked why morphin was not employed 
alone to produce painlessness; because, when mor- 



REDUCING THE PAIN OF CHILDBIRTH 5 

phin is used alone and in sufficient quantity to be- 
come effective, it not only interferes with the natu- 
ral phenomenon of birth, but it affects the centers 
of respiration as well. It was found that scopo- 
lamin did neither of these things, and when com- 
bined with a single small injection of morphin pro- 
duced remarkable results. This combination of 
drugs was a most happy one, for while anesthetic 
and hypnotic qualities are common to both, their re- 
maining properties are antagonistic and thereby 
their narcotic action is accompanied by a decided 
diminution of danger. 

The chief charm of this anesthetic from the 
mother's point of view is that there is none of that 
first sense of terror and suffocation which accom- 
panies an inhalation narcosis. No cone is used over 
the face, the drugs being administered by the hypo- 
dermic needle. The mothers, in describing to me 
their sensations after the injections, tell of a sense 
of drowsiness stealing over them, a pleasant feeling 
of don't-care-ness, which finally merges into an 
overpowering sleepiness. There is never a single 
disagreeable sensation associated in the mother's 
mind with the experience. There is no subsequent 
nausea, such as follows the use of chloroform. 
After the birth, the patient continues to sleep peace- 
fully for four or five hours, and when she awakes it 



6 THE TRUTH ABOUT TWILIGHT SLEEP 

is difficult to convince her that everything is over. 
Scopolamin has a direct effect upon the nervous sys- 
tem and the brain, causing by its action an inter- 
ruption in the mental associations or memory. 

The patient treated by hypodermic injections of 
scopolamin-morphin remains to all appearances 
normal, she dozes between pains, and though she 
may apparently awake during the actual pains and 
even discuss them with those around her, it will be 
found after the birth is over that she has retained 
no memory whatever of the events which have taken 
place since the injections began to take effect. In 
other words, the drugs have obliterated memory for 
the time being, and as an English physician has ex- 
pressed it: " If there is no memory of pain, it is 
equivalent to having had no pain, and a doctor then 
certainly has the right to speak of ' painless child- 
birth.' " 

You see, the most remarkable quality of this nar- 
cotic is that while the mother retains her normal 
muscular functions and is in such possession of her 
mental faculties that she can obey the doctor's or 
nurse's requests — can, in fact, cooperate in the en- 
tire birth process — she afterward retains no mem- 
ory of what she has done or of what has occurred, 
because of the interruption in her mental associa- 
tions, caused by the peculiar hypnotic quality of 



REDUCING THE PAIN OF CHILDBIRTH 7 

scopolamin-morphin. If messages of pain are 
flashed along the nerve wires, they have been re- 
fused admission by her memory. 

I think I can best describe the phenomenon by say- 
ing: it is just as if a message were sent over the 
telephone wires to central, but as the receiver at 
central has become disorganized, the message can- 
not be received and consequently never arrives at its 
destination. The mother, having no sense of pain 
or terror, makes no resistance to the contractions of 
the muscles ; unimpeded and uninfluenced by mental 
distress the muscles can perform their intended 
functions as nature originally intended they should. 
This fact is pointed out by several doctors, and, as 
one declared after seeing a birth conducted with 
scopolamin-morphin : 

" It was as if I had seen the natural action of a 
woman for the first time." 

An important sequence of the obliteration of all 
memory of pain in the mind of the mother is the 
subsequent abolition of the mental and nervous 
shock usually coincident with childbirth. The. 
strain of modern life upon the nervous systems of 
women results in what we call " high-strung nerv- 
ous temperaments " — a condition which causes pe- 
culiar sensitiveness to pain and mental shock. I am 
told that the rather phlegmatic and muscular Scotch' 



8 THE TRUTH ABOUT TWILIGHT SLEEP 

women of the working class suffer comparatively 
little in childbirth, while the more delicately consti- 
tuted women of the upper classes are prostrated by 
the ordeal. It is to sensitive, nervous women that 
this method has proven an inestimable blessing. I 
shall quote Dr. Kronig 2 upon this phase of the sub- 
ject : 

" The demand that we obstetricians diminish or 
abolish suffering during delivery has become of late 
years more and more emphatic. Quite other de- 
mands than those of former times are now made 
upon the nervous system of the modern woman, and 
as a consequence she more rapidly shows a nervous 
exhaustion under the influence of pain. This sensi- 
tiveness to pain is greater in those who are engaged 
in difficult mental work than in those who live by 
manual labor. As a consequence of this condition 
of nervous exhaustion in mothers of the better class, 
we find the doctors often forced to use forceps to 
terminate the birth where there is no structural con- 
dition to necessitate their use. 

" At a meeting of the Berlin Obstetrical Society 
it came to light that obstetricians were obliged to 
use the forceps in almost forty per cent, of all 
cases. 

2 " Painless Delivery in Dammerschlaf ," by Dr. Bernhardt 
Kronig. Deutsche Med. Wochenschr., No. 23. 1908. 



REDUCING THE PAIN OF CHILDBIRTH 9 

" In the hospitals, unfortunately, the cases avail- 
able for study consist for the greater part of women 
of no great intelligence, while in private practise we 
not infrequently have to deal with women of highly 
nervous temperaments — women who declare them- 
selves incapable of enduring the pain of delivery to 
the end. A doctor, in such cases, often finds himself 
facing the alternative of either ending the delivery 
operatively with forceps or of retiring in favor of 
another physician. 

" If we take the trouble to sit at the bedside of 
women of sensitiveness during the whole course of 
labor and observe the state of their nervous system, 
we are compelled to admit that in their case such 
nervous exhaustion does really set in, as a conse- 
quence of their suffering, so that the will power to 
hold out to the end is paralyzed. No one who takes 
the opportunity of observing a birth, in the case of 
a highly strung woman, from beginning to end, 
could afterward say that the physiological pain of 
birth is an advantage to the mother and must not be 
reduced. Such a statement could only be made by 
those clinicians who, having such a large number of 
cases, do not have the time, or take the trouble, to 
follow the nervous condition of mothers from be- 
ginning to the end of labor; they merely content 



io THE TRUTH ABOUT TWILIGHT SLEEP 

themselves by ascertaining occasionally how the case 
is coming on. 

" Any gynecologist who considers that he ought 
to be something more than merely an operative 
manipulator will feel that he should observe the 
nervous system of the mother; he will then not in- 
frequently notice that neurasthenic symptoms appear 
in immediate connection with the delivery. This is 
not surprising. One would rather feel astonished 
that long continued exhaustion does not occur in 
women of nervous temperament more often than is 
actually the case, when one realizes what a sensitive 
woman has to endure during birth, aside from the 
mental impressions. 

" Even earlier, during the period before the birth, 
the ground is prepared for this by numerous bodily 
disarrangements, such as nausea, loss of appetite, 
etc. As is well known, hypochondriacal moods often 
predominate in women during pregnancy. The 
woman has also heard from her friends how diffi- 
cult is the birth of a child, and how eventually 
the doctor used forceps, and then puerperal fever 
followed the birth for a long time. 

" In the case of a first child, the blood loss is 
usually relatively great and bodily exhaustion is 
added to the mental. 

" It is true that robust women can endure birth 



REDUCING THE PAIN OF CHILDBIRTH n 

without consequent injury to their nervous systems, 
but it is equally undeniable that if there is the 
slightest inclination to a neuropathic condition, 
such severe physical and mental injury results in 
a long period of exhaustion. 

"If scopolamin-morphin only reduced the per- 
ception of pain, the value of the method would 
still be great, but it goes still further, completely 
abolishing all perception of the pain in eighty per 
cent, of the cases. 

" The successful development of this method is 
principally due to the laborious observations and 
examinations of women in labor under scopolamin- 
morphin by my assistant, Dr. Gauss. 

" In this method we now possess a procedure 
which, while in no way endangering either mother 
or child, has attained the end in view, viz. : the 
complete annihilation of the perception of pain in 
childbirth in eighty per cent, of the cases, and in the 
remainder a reduction of pain to its minimum." 

In writing of the present-day horror of women 
of the danger and agony of childbirth, E. Temple 
Thurston says : 

" It is terrible to think how rapidly this most 
natural of all functions — since upon it hangs the 
existence of all the people in the world — it is ter- 
rible to think how rapidly it is shaping into the 



12 THE TRUTH ABOUT TWILIGHT SLEEP 



awesome features of a disease. Women speak of 
it as of some dreadful operation, which indeed it 
has become. More women die in childbirth now 
than ever fell its victims when the services of a 
common midwife were all that were at their dis- 
posal. Such indeed is the horror of many mothers 
of the dread experience, that a fear of the coming 
ill germinates in the mind as the child germinates." 
To those of us who believe in prenatal influence, 
it would seem an inevitable result that the child 
would be blighted by this abnormal horror and fear 
in the mother's mind during pregnancy. 

To those who have once slept the Dammerschlaf, 
there is no dread whatever concerning future births ; 
they know there will be no pain to endure during 
or after birth, they believe there is no danger for 
themselves or their children, and they rest assured 
that forceps will not be used unless complications 
make their use absolutely imperative. 

Those old psychologists, the originators of the 
Spanish Inquisition, worked out their scientific sys- 
tem from their knowledge of the effect of pain upon 
the human will. Torture anybody long enough, 
they doubtlessly argued, and you will get what you 
want — retraction, promises, political secrets, lies, 
truth, or even death. It is just this same chemi- 
cally deteriorating effect of pain upon the will 



REDUCING THE PAIN OF CHILDBIRTH 13 

which is largely responsible for the use of forceps 
to-day. I doubt if there is a normal woman in the 
world who would, before birth, entertain the 
thought of forceps with anything but horror, but 
that same woman put on the rack and tortured for 
twenty-four to forty-eight hours will beg the doctor 
to use the forceps, irrespective of injury to her 
child or herself — anything to have the agony over 
with ! The use of forceps has almost entirely been 
done away with at the Frauenklinik of Freiburg 
since the development of the Gauss Twilight Sleep. 

It is a barbaric idea that women should suffer 
in order to bring forth children. I have even heard 
the unnatural opinion expressed that the greater 
the ordeal through which the mother passes the 
more precious is the child to the mother. What an 
inhuman creed ! — yet it is evidently held to-day 
even by some of the medical profession, for I 
heard an American physician ask a mother (deliv- 
ered three days before by the humane method of 
Twilight Sleep), "Do you take the same joy in 
this child as you did in the ones you really had?" 

This poor mother, in three former births, had 
suffered the most terrible and unnecessary agony; 
the result of the birth of her third child, which she 
" really had " by aid of instruments, was such in- 
juries that she had been confined to bed with blood- 



14 THE TRUTH ABOUT TWILIGHT SLEEP 

poisoning for six months, and her souvenir of this 
very " real " birth was a stiff leg for four years. 

I can assure you that where the mothers have 
painless childbirth their joy in their babies is ten- 
fold. Many mothers have told me of the delightful 
surprise they experienced when they awoke to find 
a nurse standing beside the bed with a baby on a 
pillow, and in every case they declared that at first 
they simply could not believe the baby was their 
own, for they recalled nothing whatever of having 
given birth to the child. 

No mother needs excruciating pain to endear 
her child; the baby has had nine months in which 
to become daily, hourly more precious — months of 
planning for and of dreaming of the little new life 
— months which are the most beautiful and tender 
in all the history of a woman's inner being. 

The woman delivered painlessly, with her physi- 
cal powers conserved, her nervous system unim- 
paired, is a far more capable mother. Furthermore, 
it has been declared by several obstetricians of 
note 3 that the use of scopolamin-morphin, far 
from reducing the milk secretion, augments it ; sta- 
tistics kept in hospitals of the Twilight Sleep 
mother's capacity to nurse, verify this assertion. 

If the strength of the mothers of a nation is 

3 Drs. Kuenzer, Jusgen, Preller, and Lehmann. 



REDUCING THE PAIN OF CHILDBIRTH 15 

conserved during childbirth, if the children them- 
selves are born under normal and safe conditions, 
that nation will, within twenty years, find itself 
spending less capital on the general wards of its 
hospitals. I have been permitted to see many 
mothers within twelve to fifteen hours after de- 
livery by this method and I have never failed to 
feel astonished at their remarkable physical and 
mental condition. These mothers show no trace 
of having recently passed through the greatest 
physical convulsion known to nature. They are 
entirely free of bodily discomfort, they are amaz- 
ingly gay, and display none of the exhaustion evi- 
denced by patients who have become mothers in 
the old-fashioned, ordinary way. 

Every mother with whom I have talked has 
declared that Twilight Sleep has removed all dread 
of having future children. In fact, many mothers 
declare they do not care how many children they 
may have, now that they know the wonders of this 
method. This is an important factor, for it is well 
known that the dread of the torture of birth deters 
many a woman with a mother's heart from bearing 
children. One of the leading woman doctors of 
England has said the adoption of this method will 
" induce a rise in the birth rate." With the dread 
of the pain of birth removed, how much happier 



16 THE TRUTH ABOUT TWILIGHT SLEEP 



are those long months of the mother's waiting for 
the coming of the baby ! 

As great cowards as most of us are where pain 
is concerned, I have never yet met a woman who 
considered her own relief before the safety of her 
child. The first question every mother asks, when 
the method of painless childbirth is mentioned, is: 
"But is it safe for the baby?" It is a great re- 
sponsibility to take upon oneself to answer this 
question, and I do not do so without having made 
every possible investigation of this, the most im- 
portant phase of the entire subject. At the Con- 
tinental Maternity, which I have mentioned earlier, 
where over five thousand women have been deliv- 
ered in Twilight Sleep, the statistics kept during 
the past nine years, since the adoption of the 
method, as compared to those of the preceding nine 
years, show that the rate of infant mortality has 
been reduced, since the adoption of Twilight Sleep, 
by a little over three per cent. Moreover, the rate 
of infant mortality in this hospital is markedly less 
than the figures of the general statistics of the 
Ducal State in which the hospital is located. 

The consensus of opinion of the doctors in sixty- 
nine medical reports which I have before me is that 
scopolamin-morphin is without danger to the child. 
Among a series of 2,130 Twilight Sleep cases, only 



REDUCING THE PAIN OF CHILDBIRTH 17 

1.1 per cent, of the children died up to the third 
day, while among five hundred consecutive cases 
in another hospital only seven children (1.4 per 
cent.) died during the first nine days. An investi- 
gation of the amount of scopolamin given the moth- 
ers of 318 children, of whom 285 were still living 
after one year, proved curiously enough that the 
mothers of children still living had received the 
larger injections of scopolamin, 4 which would cer- 
tainly indicate that the injections had nothing to do 
with the deaths of the children. 

In the early days of experimentation with sco- 
polamin-morphin it was at first difficult to deter- 
mine the exact dosage which would produce an 
insensibility to pain without coincident evil effects. 
In these first tentative experiments the mother was 
frequently given an injection too early in the first 
stages of the birth, or the amount injected was too 
great, or the last injection was administered too 
late in the final period of birth, and as a consequence 
of faulty technic the child was sometimes born in a 
sleepy condition, which seemed rather alarming 
until it was found that, even if no artificial efforts 
at resuscitation were made, the infant soon returned 

* The mothers of children still living after one year had re- 
ceived at an average .00131 g., while the other mothers had re- 
ceived at an average .00126 g. 



18 THE TRUTH ABOUT TWILIGHT SLEEP 

to a normal condition and proved none the worse 
for its temporary condition of intoxication. As 
experience grew and the numbers of patients treated 
by this method reached into the thousands, a per- 
fected system of dosage naturally established itself, 
and the children then came into the world in an 
entirely lusty condition of wide-awake-ness. 

When the correct injections are given and at 
least four hours elapse between the first injection 
and the birth of the child, the baby is not affected 
in the slightest. As one practitioner has said: 
"If the child is born sleepy, it is not the fault of 
the method but the fault of the manner of dosage." 
Dr. Frigyesi 5 says : " The injections of scopola- 
min-morphin never caused the death of a single 
child." While Dr. W. A. Brodski 6 of Moscow 
has voiced the general opinion expressed by the 
British doctors who employ this method: "If 
correctly administered, scopolamin-morphin is en- 
tirely harmless to both mother and child." 

I have been asked: "If you were to have an- 
other child would you have this method of painless 
childbirth?" I certainly should, even if I had to 
cross the world to find a physician who employs it. 

B Gesellsch. d. Aerzte. Budapest, 1909. 
6 At the Eleventh Piragow Congress of Doctors held at St. 
Petersburg (Petrograd) in 1910. 



REDUCING THE PAIN OF CHILDBIRTH 19 

The only way in which the general adoption of the 
method by the entire medical profession can be 
brought about, is by the mothers themselves. Let 
every mother take up the fight for herself and her 
fellow-mothers and within a few years, as Dr. 
Birchmore says, " the exhausting ordeal of mother- 
hood " will be " gone to be seen no more." I want 
to spare all whom I love needless pain, and I want 
all mothers who are personally unknown to me to 
realize that there is no longer any necessity for 
them to suffer the " pains of maternity." 

All told, there are now medical records of over 
twenty thousand births in Twilight Sleep, while 
doubtless there have also occurred many cases of 
which no records have been kept. 

The method has stood the test of experiments 
since 1903. Many doctors in Great Britain who 
reported in 1907 and 1908 on their initial cases, are 
to-day using the method with an ever-increasing 
faith in its effectiveness and safety. A method 
which can be proved to insure painlessness in child- 
birth with safety to both mother and child is of 
importance to all the women in the world; which 
is to say, it concerns eight hundred and eleven mil- 
lions, six hundred and fifty thousand women. 



II 

The Mother's Experiences 

* 6 T'E> much rather have a baby than a bad cold." 

X The mother who voiced the amazing pref- 
erence of childbearing to cold was Frau Anna 
Straub, the wife of a Freiburg-in-Baden school- 
master. 

There is a very old German proverb — " It is 
easier to bear a child than to have a tooth pulled. " 
In the face of the above remark, this adage would 
seem to have been nothing less than an inspired 
prophecy. 

I sat beside Frau Straub on the particular place 
of honor on the holy German sofa and begged her 
to tell me all about her experience in childbearing. 

" My brother is a doctor," she said, " and when 
he found I was to become a mother, he told me to 
go to our Freiburg Frauenklinik to have a scopo- 
lamin birth. 

" I had never heard of such a thing, neither had 
my mother. 

" Then my brother told me it was something 

20 



THE MOTHER'S EXPERIENCES 21 

which the doctors injected with a hypodermic needle 
to take away all pain in childbirth. 

" I listened respectfully, but I thought to myself, 
I don't know whether I want experiments tried on 
me or not; I shall probably have the baby just as 
my mother had me. But I didn't. As the time of 
birth drew near I made up my mind to go to the 
Frauenklinik, though I was still a little undecided 
on the question of having that new thing used, but 
I changed my mind on the subject with the first pain. 
I even begged for it. 

" Dr. Vogt, who was attending me, said, ' I will 
give you an injection as soon as the pains begin to 
come at intervals of ten minutes apart. Don't be 
afraid, there will be no severe pains to endure at 
all, just be patient and believe me.' 

" But I couldn't. 

" I grew so excited and nervous over the un- 
knownness of what was coming I made it more dif- 
ficult for the scopolamin to take effect when it was 
eventually given me. 

" They made the injection in my hip and I re- 
member quite distinctly receiving three injections, 
then I simply grew drowsier and drowsier until I 
felt as though I were in a ' Dusel ' — as the German 
slang saying is for drunken stupor — and then I 
was asleep. 



22 THE TRUTH ABOUT TWILIGHT SLEEP 

"But though I thought I slept soundly and peace- 
fully and knew nothing of what was going on about 
me, I was, nevertheless, behaving very badly, as the 
result of my great excitement of mind beforehand, 
for they afterward told me I had had a perfect 
wrestling-match with the head nurse. 

" It was about ten at night when I went to sleep 
and the baby was born between five and six in the 
morning, but I slept on soundly until about nine 
o'clock and woke up feeling as one feels after a 
beautiful night's rest. 

" For the moment I had quite forgotten where I 
was, and that I had, only the night before, been in 
such a state of nervousness over the expected birth, 
but as I opened my eyes and saw that I was in the 
Frauenklinik it all came back to me. 

" I then realized, with a sense of terror, that I 
was there for the purpose of childbirth, which I 
thought I had yet to go through. 

" Then I heard the voice of a nurse, asking if I 
felt hungry. I said yes, and I then saw that she 
was standing there with a bowl of ' Gerstenschleim ' 
(a thin sort of gruel) and then she said, 'It's a 
girl.' ' What's a girl? ' said I, and she said, ' Your 
baby, of course/ 

" I don't think I ever felt so happy before in my 
life, for I suddenly realized it was all over, the baby 



THE MOTHER'S EXPERIENCES 23 

was safe, and I had not suffered at all. In about 
two hours the nurse said she would like to make 
the bed and asked me to get up, so she could do so. 
I did and stood near while she beat and turned the 
mattress. I felt perfectly well. At five that after- 
noon I had my usual cup of afternoon coffee, and at 
supper that night, I remember, I ate two boiled eggs. 

" The next day I was ravenous and ate every- 
thing I wanted, including a fine big piece of beef- 
steak for dinner. 

" On the afternoon of the second day, I held a 
perfect levee, and all my friends came in to see me 
and my little girl. 

" My mother was really horrified by such revolu- 
tionary behavior. 

" On her asking the doctor if he did not think it 
unwise for me to be having such excitement, the 
doctor replied, ' Your daughter is no longer under 
treatment; she is merely under observation/ 

" On the third day I walked all about the halls 
of the Klinik, but as it was winter and very cold 
I did not go outdoors." (Frau Straub really said 
this quite apologetically. ) 

" The baby," she resumed, " was born on Friday 
and on Tuesday we had a fine christening down- 
stairs, which I attended, and we named the baby 
Marga." 



24 THE TRUTH ABOUT TWILIGHT SLEEP 

The tone with which she said these final words 
was the tone with which one should read the closing 
lines of a fairy story that end6 : 

" And then they were married and lived happily 
ever after." 

But thanks to the German professor-doctors, this 
was not a fairy tale I was listening to — it was the 
simple, truthful statement of a mother telling me, 
as clearly as she could recall, the actual experience 
of bringing her first child into the world. 

I then asked for the still more matter-of-fact de- 
tails of the expense of such a luxurious and delight- 
ful childbirth. 

She said there were four classes of childbirth to 
be had in the Frauenklinik and that she had experi- 
enced that of the second class. 

For the services of doctor and midwife, if mat- 
ters took their ordinary course and there were no 
complications, the charges were fifty marks 
($11.90). 

For board and bed five marks ($1.19) a day. 

For baby, if suckled by the mother, fifty pfennigs 
(12*4 cents) per day. 

It is preferred that mothers do not bring infant 
clothes; the Klinik supplies them, and the linen is 
the same for all classes. 



THE MOTHER'S EXPERIENCES 25 

Frau Straub's bill for medicine had been nine 
marks ($2.14) in all. 

Of her second child's birth, three months ago, 
there was practically nothing to tell, for as she felt 
no fear or excitement beforehand, she had gone to 
sleep more quickly and had really had no experience 
at all. The only individual characteristics of the 
second birth were as follows : Baby born at two 
A. m. ; sat up next day at table to eat her midday 
dinner; baby born on Saturday, the mother attended 
christening downstairs on Tuesday. (Tuesday is 
evidently christening day at the Frauenklinik. ) 

" You would like to see her — the little bundle ? " 
she asked. 

"Yes, indeed — both of them, if I may," I 
begged. 

She returned with the last baby in her arms, the 
little Marga clinging to the edges of her mother's 
pretty German apron. 

They were a wonderful trio. 

Frau Straub is a most splendid Teutonic creature 
of the Wagnerian type. The soundly sleeping 
" bundle," wrapped in a blue thing like an Indian 
papoose, never knew a thing about my extravagant 
admiration of her. The red-cheeked, plump little 
Marga in her red pinafore, dodging from one side 



26 THE TRUTH ABOUT TWILIGHT SLEEP 

of her mother's skirts to the other in her embarrass- 
ment, was a replica in miniature of her robust 
mother. 

" They don't look as if scopolamin was very in- 
jurious, do they ? " asked Frau Straub with a merry 
smile. 

Mrs. Emmet of New York was the first Ameri- 
can mother who had a child in Dammerschlaf. Six 
years ago she merely chanced to be in Freiburg at 
the time of her confinement and went to the Frauen- 
klinik and so stumbled by accident upon the scopola- 
min method. 

She was so charmed by her first experience that 
she has since returned to Freiburg for the birth of 
two other children. Mrs. Emmet told her friends 
about painless childbirth and several of the friends 
decided to follow her example. They braved the 
Dammerschlaf, found it perfect and told their 
friends. 

Now a most significant feature of all these 
American mothers is that in every case but one they 
were mothers who had been injured in former 
births; they went to Freiburg because of further 
dreaded complications and agony. 

The exception was an American who found her- 
self at the age of thirty-eight about to become a 
mother for the first time; having heard the per- 



THE MOTHER'S EXPERIENCES 27 

sonal experience of a friend who had followed Mrs. 
Emmet's example, this mother-to-be, realizing the 
danger of a first birth at her age, decided she would 
stand the best chance of a safe delivery under the 
scopolamin-morphin method. 

In these American mothers Drs. Kronig and 
Gauss did not have one normal case with which to 
deal ; they were mothers on whom forceps had been 
used in former births, women with tendency to 
hemorrhage and placenta previa, one with a four 
years* disabled leg from blood poisoning resulting 
from use of forceps, and one of thirty-eight becom- 
ing a mother for the first time. 

One might say surely it would be scarcely fair to 
judge the method of Dammerschlaf by the cases of 
these women; in the face of this how much more 
emphatic then are the results. We find that in 
every one of these complicated cases the success of 
scopolamin-morphin was absolutely perfect. In no 
case were the forceps used, there were no dis- 
agreeable side effects from the drugs, no child was 
born in an intoxicated condition, the mothers were 
in every case oblivious of the entire birth process, 
none of them suffered a pain either during or 
after birth, they all made immediate recoveries 
and all were up and about the fifth day, some ear- 
lier. 



28 THE TRUTH ABOUT TWILIGHT SLEEP 

Strangely enough, of the eight American women 
who have experienced Twilight Sleep I found seven 
still remaining in Freiburg. This fact seemed so 
odd that I asked : " Haven't any of you people 
homes?" They laughed and explained. Two 
were staying in Freiburg because they had German 
wet nurses and they did not want to make a change 
of " cow " until the babies were older. 

One had returned to Freiburg to bring her sister- 
in-law to be operated upon by Dr. Kronig. One 
was married to a professor in the university. 
One had returned to Freiburg to study the method 
for professional purposes. One had just been de- 
livered of a child at the Frauenklinik. As for the 
seventh, I am sorry to say I can tell you nothing, 
as she did not care to discuss the birth of her baby. 
The very different attitude of the other scopolamin 
American mothers was embodied in a reply made 
to me by one of them, when I asked her if she had 
any objection to my giving publicity to her experi- 
ence. "Objection!" she cried. "Why, we are 
all so anxious to make this thing known to the 
women at home we'd welcome you and tell you 
everything we know about scopolamin even if you 
were going to publish it in the Police Gazette! " 

It was one afternoon at tea in Freiburg when 
all my guests were American mothers who had been 



THE MOTHER'S EXPERIENCES 29 

confined under scopolamin-morphin. Mrs. Sargent 
of Nebraska, whose scopolamin baby's second 
month birthday party I had attended a few days 
before, first told her experience. 

" I didn't even feel the injection of scopolamin," 
she said, " for they first used cocain on the spot 
before using the hypodermic needle. Very soon 
after I found myself growing drowsy and in about 
half an hour I fell off to sleep just as naturally as 
I do on any night when going to bed. 

" The next thing I knew I was awake and I 
heard the sympathetic voice of Dr. Kronig saying, 
' All ees well,' and then I thought to myself, ' I 
wonder how long before I shall begin to have the 
baby/ and while I was still wondering a nurse 
came in with a pillow and on the pillow was a baby, 
and they said I had had it — perhaps I had — but 
I certainly can never prove it in a courtroom." 

" That's the only thing I don't like about it," said 
another mother ; " there is nothing to talk about 
afterwards. You just go to sleep and have a pleas- 
ant but vacuous night and when you wake up they 
present you with a perfectly brand new baby and 
tell you it is yours, and you have to accept it on 
faith and feed it and keep it." 

" And on the fifth day you get up for good and 
all," said Mrs. Cecil Steward of New York; " that's 



30 THE TRUTH ABOUT TWILIGHT SLEEP 

the fashionable day with us, though some were 
more precocious." 

" And on the sixth day you get into a motor," 
continued another, " and you go about fifty miles 
somewhere up into the Black Forest and there you 
have tea and — well, that's about all." 

" What I like about Dr. Kronig," said one Ameri- 
can, " is he doesn't believe in the goodness of pain. 
He even thinks pain, and the mental condition re- 
sulting from it, a positive hindrance in childbirth." 

" This relief of suffering in childbirth," said Mrs. 
Mary Boyd, " is not only a humane step taken by 
science to benefit motherhood, but it also promises 
to raise the function of childbirth from a gross and 
primitive physical agony to a normal unimpeded 
muscular process which can be entirely directed by 
the obstetrician." 

" I was a bit hysterical," said one mother, " and 
they just gave me a small whiff of chlorethyl which 
made me unconscious for about five minutes, which 
caused the very first injection of scopolamin-mor- 
phin to take immediate effect." 

" The only after effects of scopolamin," said 
Mrs. Boyd, " are, a slight defect in the eyesight 
[something like that caused by belladonna], which 
lasts about forty-eight hours; then for about half 
a day there is sometimes a trifling numbness in the 



THE MOTHER'S EXPERIENCES 31 

hands and feet, a disposition to break out in per- 
spiration, and a dry throat which makes you want 
to drink water, and that is literally all." Compar- 
ing this to the after effects of other anesthetics one 
must feel that the aftermath of scopolamin is very 
insignificant. 

I then inquired about the expense of having these 
American first-class babies. 

For room, according to size, eight ($1.90) to 
fifteen marks ($3.57) a day. Child bed supplies, 
twenty marks ($4.76) ; midwife's fees, fifteen 
marks ($3.57). 

For wet nurse, three marks and fifty pfennigs 
(84 cents) per day. 

Incidentals from forty ($9.52) to one hundred 
marks ($23.80). 

The doctors' fees vary according to doctor and 
case, but they are always exceedingly reasonable. 

I found that the experiences of these American 
mothers are entirely typical, and that after one has 
heard the stories of a dozen or more mothers the 
similarity of detail and a lack of extiting adventure 
robs the subject of variety. 

The experience of a mother of the German no- 
bility, who most courteously and gladly gave me 
every detail of her second baby's birth, is, as you 



32 THE TRUTH ABOUT TWILIGHT SLEEP 

will see, very similar to the foregoing instances, 
except in one interesting detail. 

"I had had a frightful experience in Berlin, ,, 
she told me, " with the birth of my first child, so 
when I found the birth of my second approaching 
I decided to come to Freiburg to the Frauenklinik, 
not knowing, however, anything of Twilight Sleep, 
but merely because of the reputations of Dr. Kronig 
and Professor Gauss. Naturally I was a bit ner- 
vous when they suggested the use of the, to me, 
unknown drug in my delivery, but when they said 
I would know no pain, the memory of my agony 
in Berlin decided me. 

" The injections of scopolamin were made on 
either side of my chest above the breasts " — [I pre- 
sume the location had something to do with her 
nobility] — " and within twenty minutes I found 
myself going to sleep. I awoke at one time suffi- 
ciently to see that there were doctors and nurses 
around me, but I had no desire to speak to them 
and I was unconscious of any pain. The Geheim- 
rath (Dr. Kronig) happening to look at me ex- 
claimed, 'Why, she is awake/ and quickly laid a 
cloth over my face. As soon as the visual impres- 
sions were removed I immediately fell asleep again, 
and when I awoke the next morning I was perfectly 
amazed when the nurse presented me with a little 



THE MOTHER'S EXPERIENCES 33 

girl. On the fourth day I was walking about, feel- 
ing absolutely well. In Berlin I was in bed four 
weeks and did not recover my health for months." 
The one significant detail of this experience to 
me is that out of all the American and German 
mothers whom I met in Freiburg, this is the only 
case of a mother consciously awakening, even mo- 
mentarily, after the Dammerschlaf was established. 

The mothers of the fourth class, delivered in 
the free ward of the Klinik, are very difficult to 
get at, but I found one — a poor girl who had de- 
liberately become a mother for the professional 
purpose of becoming a wet nurse. In her simple 
way she put the whole matter in a nutshell : 
" Why, you don't know a thing about having a 
baby, do you? " That was all she had to say. 

In the case of Frau Stammnitz, the wife of the 
Stadt Architect of Baden, the doctors had an ex- 
ceedingly difficult case with which to deal. It was 
the fourth child, and her experiences in childbirth 
without scopolamin had hitherto been as follows : 
The birth process of her first child had continued 
in unabated suffering from a Sunday until the fol- 
lowing Thursday and then forceps eventually had 
to be used to terminate the birth ; she was badly torn 



34 THE TRUTH ABOUT TWILIGHT SLEEP 

and the wound not being properly attended blood 
poisoning resulted and it was a question for weeks 
whether her life could be saved; she was confined 
to the bed for two months. Her second childbirth 
continued over the period of three days; there was 
a severe hemorrhage from a bursted vein from 
which she lost over a pint of blood. The third 
birth consumed three days and left her with hernia 
of the navel. After these frightful experiences 
Frau Stammnitz was persuaded to go to the Frauen- 
klinik for the birth of her fourth child under Twi- 
light Sleep. 

In all three of the former births without scopola- 
min there had been a marked weakness of labor, 
so it is not at all surprising to find that after the 
first injection of scopolamin-morphin all labor 
ceased. The doctors had to wait for twelve hours 
before labor recommenced, the second injection 
was, therefore, not given until after the thirteenth 
hour. This injection did not diminish the action 
of the labor, but neither did it succeed in reducing 
the pain. The third injection also failed to pro- 
duce a condition of Dammerschlaf. It was not 
until the fourth injection was given that Frau 
Stammnitz became oblivious of the birth process, 
but from that time on the drug was effective and 
she did not realize the final expulsion of the child. 



THE MOTHER'S EXPERIENCES 35 

The birth consumed forty-eight hours, which we 
find on comparison with the length of former births 
was a distinct improvement. No forceps were 
used, there was no hemorrhage, the birth was en- 
tirely spontaneous. 

Frau Stammnitz continued to sleep for four and 
a half hours after the birth and then awoke to find 
herself not only free from discomfort but re- 
freshed. The fifth hour after birth she got up and 
walked about the room. 

In the afternoon she was carried downstairs and 
then, on the arm of her husband, walked constantly 
for one hour about the Frauenklinik grounds. A 
woman sitting in the garden came up to Frau 
Stammnitz and said, " Excuse me, madame, but is 
it possible that you are the lady who could not have 
her baby yesterday? " 

In telling me of her experience Frau Stammnitz 
said : " You will doubtless hear the objection 
brought by the opponents that scopolamin is not 
thrown off as quickly as is claimed by Gauss and 
that in reality the mother is left in a semi-nar- 
cotized, stupid condition for a day afterward. 
Nothing could be further from the truth in my case ; 
to refute that claim I would like to tell you of my 
first day after the birth of my scopolamin child: 
He was born on the 9th of July and it so chanced 



3 6 THE TRUTH ABOUT TWILIGHT SLEEP 

that the ninth is also the birthday of our Grand 
Duke ; this particular birthday was the first that the 
Duke had celebrated since his accession. 

" Six hours after the birth of my boy it occurred 
to me that I should commemorate the occasion by 
writing a poem to the Grand Duke. I thereupon 
consumed the entire forenoon in the composition of 
a poem of four pages. This surely would not in- 
dicate that my mental faculties were dulled by the 
drug." 

The remarkable activity of Frau Stammnitz dur- 
ing this first day after a forty-eight hours' birth 
was indeed wonderful, embracing, as it did, not 
only the hour's walk in the garden during the after- 
noon but the creation of a long poem in the morn- 
ing. Even if it is quite aside from the subject- 
matter of this chapter, I would like to tell you of 
the poem and its delightful sequel. The subject of 
the first part was the excessive patriotism shown 
by the boy which had inspired him to prolong his 
mother's labor for forty-eight hours in order that 
he might be the first subject born on the first anni- 
versary of the birthday of the Grand Duke cele- 
brated by Baden. Frau Stammnitz then recalled 
to the Duke's memory that at the age of ten she 
had been appointed to be the deliverer of a bouquet 
of flowers, on a certain great occasion, to his 




Dr. Bernhardt Kronig, who, with Dr. Gauss, developed 
the Twilight Sleep method 



THE MOTHER'S EXPERIENCES 37 

mother, the Grand Duchess. His mother on ac- 
cepting the flowers had greatly disconcerted the 
little girl by asking, " Do you like knitting? " The 
child was miserably confused, as she did not dare 
speak the truth of her sentiments in regard to this 
art so sacred to Baden — in fact, to all Germany. 
Great was the relief of the little girl when the 
Queen of Sweden, sitting beside the Grand Duch- 
ess, came to the rescue by saying, " If you don't 
like knitting, say so. I hate it myself." 

In reminding the Duke of this incident Frau 
Stammnitz said, " This same little hate-knitting 
girl is the mother who now, six hours after the 
birth of her boy, lays at the feet of Your Highness 
a loyal subject and future soldier of Baden, con- 
soled in that thought that she is not the mother of 
a much-desired girl." 

A personal letter of pleased appreciation arrived 
in a few days, then two months later, when Frau 
Stammnitz had just issued invitations for the bap- 
tism next day of her baby, another letter arrived 
from the ruler of Baden; the Grand Duke wrote 
to request the privilege of becoming the godfather 
of the boy. " You may imagine how quickly I sent 
word to all my friends canceling the invitations 
for the next day," laughed Frau Stammnitz. 

On the following Sunday the Grand Duke became 



38 THE TRUTH ABOUT TWILIGHT SLEEP 

the godfather of his little scopolamin subject and 
a few days later there arrived a most beautiful 
silver cup on which was engraved the royal crest 
and below that the monogram of the son of Frau 
Stammnitz. 

Before the Twilight Sleep was developed there 
were only two sisters (nurses) in the first-class 
maternity ward of the Frauenklinik, but so inter- 
ested was the Grand Duke in the development of 
the method, he made a very handsome gift to the 
Frauenklinik which enabled them to increase the 
maternity force of nurses to five. This interest in 
painless childbirth taken by the Grand Duke Fred- 
erick II and the Grand Duchess Hilda, and their 
generous assistance to the Frauenklinik, has a 
touching pathos for the reason that these much be- 
loved and kindly rulers of Baden are childless. 

" It is also claimed," said Frau Stammnitz, " that 
scopolamin affects the mental development of the 
child. As to that, I can only say that, in spite of 
the rule prohibiting the admission of children into 
our schools before the age of six, such was the pre- 
cocity of our boy, this rule was set aside in his case 
and he was admitted when five and a half." As 
for this boy's physical strength, a little example will 
suffice. On his first day at school, when questioned 
about himself by the teacher, childlike, he proudly 



THE MOTHER'S EXPERIENCES 39 

stated that he was the godson of the Grand Duke 
Frederick. At recess, several older boys came up 
and one said, " We don't like liars in this school. 
When a boy lies he has to fight. Now take back 
what you said about the Grand Duke." The 
Stammnitz boy said : " It's no lie — I'll bring my 
cup to show you to-morrow — but I'll fight you 
just the same," which he did with such success that 
the fights of that day were the last ones he has ever 
had in that school. 

Frau Bissinger, the English wife of a German 
civil engineer, is the mother of four scopolamin 
children. Her first baby was born far up in the 
Black Forest mountains, the scopolamin being ad- 
ministered by the village doctor. " While miti- 
gating the pain," said Frau Bissinger, " the injec- 
tions of scopolamin-morphin were not a complete 
success; the physician was inexperienced and knew 
much more of the theory of Dammerschlaf than of 
the actual practise. I remember how infuriated I 
was. This doctor showed rne an object for the 
third time and I assured him I recalled it perfectly. 
He replied, * You only think you recollect it ; as a 
matter of fact you do not.' Then when I told him 
I was still suffering acutely, he calmly told me I 
only thought I was suffering and that after birth 



40 THE TRUTH ABOUT TWILIGHT SLEEP 

I would find I had suffered nothing. He was en- 
tirely mistaken; I recalled all the pains distinctly 
up to the latter part of the birth when the injections 
finally did become effective and obliterated con- 
sciousness of the end. 

" It was not, however, until I had my second 
child at the Frauenklinik under the care of Dr. 
Kronig and Professor Gauss that I realized the 
tremendous difference made by the personal skill, 
science, and technic of the doctors conducting the 
Dammerschlaf. The Twilight Sleep of Gauss was 
in no way related to that of the Black Forest doc- 
tor. I suffered nothing whatever during the birth 
process of my second child at the Frauenklinik. I 
merely recall the occasion as one of a delightful 
night's sleep followed by a very pleasant day on 
which my most intimate friends called to congratu- 
late me on the birth of my first son. 

" This birth robbed me forever of fear of future 
births, for I knew as long as I lived within reach 
of the Frauenklinik I need never suffer a pang — 
and I haven't. Of the third and fourth births 
there is nothing to tell, for I knew nothing what- 
ever of either births; I recovered immediately and 
my health has seemingly been bettered by every 
birth until — well look at me now ! " I looked, 



THE MOTHER'S EXPERIENCES 41 

and what I saw was a most beautiful woman of 
apparently about twenty years of age, a picture 
of perfect health, strength, and beauty. Frau Bis- 
singer is a representative scopolamin mother. 

On the faces of these mothers are written no 
lines of pain, their eyes are clear, their flesh is firm, 
and they have no nerves. As a preserver of youth 
and beauty alone, the Dammerschlaf should make 
a wide appeal to all women. One of the most 
amazing things of all is that out of dozens of Ger- 
man and American mothers whom I met in Frei- 
burg, I did not find one mother who had felt the 
slightest pain after birth. 

In the cases of German mothers, who have never 
borne children without scopolamin, I found an evi- 
dent surprise on their part that I should inquire 
about pain or soreness or bearing down after birth. 

One of these fortunate mothers replied : " But 
surely no woman ever suffers anything after the 
birth is over ! " The remarkably quick recovery of 
all Dammerschlaf patients would seem to prove 
beyond a doubt that the slow convalescence of the 
ordinary confinement case is largely due to the 
nervous and mental shock resulting from prolonged 
and exhausting agony. At the Frauenklinik, after 
birth, they make the mothers perform certain bed- 



42 THE TRUTH ABOUT TWILIGHT SLEEP 

exercises (to be described later), which correct the 
relaxation of the uterus, and reestablish a normal 
muscular condition. 

The patients do not have to remain in bed in a 
flat position, and there is no necessity for bandages. 
As a rule, they get up and walk about their room 
for a short time the first day, the second day they 
go to one of the sun parlors of the klinic and walk 
about the halls, on the third day they either go for 
a walk outside, or a ride in a motor. In fact, the 
mothers feel so very well it is difficult for the doc- 
tors to restrain them from over-exertion and from 
leaving the klinic too soon. 

Judging only by their condition of physical com- 
fort the mothers forget the drain on the system 
of the past nine months, the tension of the muscles, 
the great general bodily strain of birth, all of which 
should undoubtedly be followed by a reasonable 
amount of rest and relaxation. I remember hear- 
ing a mother say to Dr. Gauss on the second day 
after the birth of her baby, "Oh! I feel so well, 
it's all foolishness keeping me in bed. I want to 
get up and tango." "All right," laughed Gauss; 
" I make the engagement to tango with you to- 
morrow morning." This was a woman who had 
been a helpless invalid for years up to the time of 
this scopolamin birth ! 



THE MOTHER'S EXPERIENCES 43 

The Twilight Sleep mothers of my acquaintance 
in Freiburg were mothers of children ranging in 
age from one day to seven years, and in every case 
I found the mothers in a state of remarkably good 
health. 

I was sent to Freiburg in May, 19 14, by The 
Ladies' Home Journal, to investigate painless child- 
birth. 

After writing my article on the mothers' experi- 
ences, for this magazine, I decided to remain to 
investigate the subject from the medical point of 
view. The American mothers may ask: "If this 
method has been in use for nine years in Germany, 
how is it that we mothers of America have heard 
nothing of it? " It is a question which we may all 
well ask. But for the word-of-mouth propaganda 
of mothers who have had the Dammerschlaf and 
the investigation of the method by American writ- 
ers, the lay public would still have no knowledge 
of scopolamin. 

An American mother who had been delivered of 
a child some years ago under scopolamin-morphin 
in Freiburg found herself in New York about to 
become a mother again; she knew of one American 
physician who had remained in Freiburg for the 
unprecedented time of six months studying the 



44 THE TRUTH ABOUT TWILIGHT SLEEP 

method, so she wrote Dr. Kronig asking if he 
thought, it would be safe for her to go to this 
American doctor for the birth of her next child. 
Dr. Kronig replied : " I cannot advise you. I 
must however remind you of the fact that the 
physician has only had six months' study of sco- 
polamin-morphin. ' ' 

And yet during my residence in Freiburg I saw 
doctors of all European nations, England and 
America, come for a few days' or a week's investi- 
gation of births under scopolamin-morphin and go 
away with positive opinions on the merits or de- 
merits of the method! The literature of scopola- 
min-morphin is as yet largely confined to Germany 
and is scattered throughout the German medical 
magazines. It took me three months to collect and 
translate all the reports upon the subject. I was 
particularly careful to obtain all the reports of 
Gauss' opponents and the records of the Conti- 
nental hospitals where the method has failed, for 
it is only by a conscientious study of both sides 
that one can arrive at a fair conclusion. 

Fortunately I completed my last translation on 
the 25th of July. Already there were disquieting 
rumors of war in the air and Baden was palpi- 
tating with unsuppressed excitement. As my train 
left on the night of the 26th, I departed to the 



THE MOTHER'S EXPERIENCES 45 

music of " Deutschland iiber Alles " — bursting 
from the throats of hundreds of patriotic students 
on the platform of the Freiburg station. As I 
now, three weeks later, write these lines, I am sad- 
dened by the thought that Dr. Gauss — the man 
who has given nine years of his life to the develop- 
ment of this method of Dammerschlaf, is now at 
the front, as a surgeon and a reserve of the German 
flying corps. 

I pray Heaven that this book is not destined to 
be a memorial : may it only prove to be a study of 
the early work of a man who was spared to con- 
tinue the researches he was engaged upon when 
interrupted by the cruel call of war — the develop- 
ment of the use of radium in cancer. 

Now that this great tragic war has cut Germany 
off from the outside world, Freiburg has become as 
inaccessible to American mothers as the poles, and 
travel to Great Britain is not pleasant. It is, there- 
fore, strangely forced upon the American physi- 
cians to give their women at home what they can 
no longer go abroad to seek. The time has come 
when we mothers must unite in a unanimous appeal 
to the American medical body for an unprejudiced 
investigation by them of Twilight Sleep, carried out 
with a strict adherence to the Gauss rules. 

That this method has failed in some Continental 



46 THE TRUTH ABOUT TWILIGHT SLEEP 

hospitals is a matter of very serious importance, 
and for that reason I shall give a thorough account 
of all these failures in the hope that like failures 
and danger to mother and child shall be avoided 
when the method is generally adopted in America. 
The Freiburg method has been successfully 
adopted by four other large European clinics, viz. : 
Cracow, Budapest, Diisseldorf, and Stuttgart, while 
in Great Britain, Twilight Sleep is being used with 
perfect success in many large maternity hospitals 
as well as in private practise. Remember this al- 
ways: others have failed in a few dozen or a few 
hundred cases; Gauss has succeeded in over five 
thousand ! 



Ill 

My Visits to the British Doctors 

BEING tremendously impressed with the fact 
that even the earliest British reports on Twi- 
light Sleep were records of success, I decided in 
October, 1914, personally to visit several of the 
most prominent doctors whose reports I had read 
with much interest at the library of the British 
Medical Association. 

Travel is difficult in Britain during these trou- 
blous war times and no one leaves home unless 
forced to by business, but I feel most richly repaid 
for my trip, for I now realize that Twilight Sleep 
is not merely being experimented with here and 
there by British physicians, but I know it to be 
a permanently established institution in the British 
Isles. 

I am so tempted to tell you of the hundreds of 
British wounded I saw being brought into the in- 
firmary at Edinburgh, of the sixteen searchlights 
playing on the North Sea from the forts under the 
Forth Bridge as our darkened train sped across, 
of the hotel full of officers at Dundee (I was the 

47 



48 THE TRUTH ABOUT TWILIGHT SLEEP 

only woman there), of the three carloads of Bel- 
gian wounded with whom I traveled from London 
to Bristol, of seeing the poor survivors of the Hawke 
brought into Aberdeen, of the cartloads of little Bel- 
gian children going through the London streets, 
but I must remember I am not writing of war and 
disaster, but of life and hope for mothers, and re- 
strain myself. 

There is, however, one thing which I can tell you 
— one night I was groping about darkened Edin- 
burgh (we expected a Zeppelin raid nightly) and 
I suddenly noticed a dim street light glinting on a 
brass plate on a house just in front of me; I walked 
up to read : " Sir James Simpson " — the house of 
the man who first relieved woman's pain in labor! 
It was a coincidence of a really thrilling quality. 
How curious that I should stumble across the old 
home of the pioneer of painless childbirth! I 
thought of the vast strides which medical science 
had made since that first delivery of Queen Vic- 
toria's and of how glad Sir James Simpson would 
have been to know that his dream of woman's re- 
lief in childbirth had come true at last — nowhere 
is it more of a reality than in Edinburgh itself. 

No man in Britain has a more enviable profes- 
sional standing than Sir John Halliday Croom, Pro- 



MY VISITS TO THE BRITISH DOCTORS 49 

fessor of Midwifery in the University of Edin- 
burgh. 

The fact that Sir Halliday Croom has employed 
the scopolamin-morphin method both in the ma- 
ternity hospital and his private practise in Edin- 
burgh since 1908, is alone sufficient guarantee to 
all mothers of the safety and efficacy of Twilight 
Sleep. Although Sir Halliday Croom has been a 
lecturer in the University of Edinburgh for over 
thirty years, he is in the very prime of life and one 
feels that the zenith of his power is not yet reached. 
With this great obstetrician on our side, the mothers 
may well feel assured that their battle for the gen- 
eral adoption of painless childbirth will eventually 
be won. 

" Am I justified in assuring the mothers that this 
method is without danger to their babies? " I asked. 

Sir Halliday Croom replied without a moment's 
hesitation : 

" Yes. When properly used scopolamin-morphin 
is absolutely without danger to the child. If the 
child is born sleepy, it is the fault of the manner of 
dosage, not of the method." 

He added that when the child is born intoxicated 
the inexperienced physician often employs violent 
means of restoration, which does far more harm 
than good. 



50 THE TRUTH ABOUT TWILIGHT SLEEP 

A good maxim for the treatment of sleepy babies 
is, " Let them alone and they'll come to." 

I was not surprised to find that Sir Halliday 
Croom welcomes this crusade of mothers for pain- 
less childbirth, for he is such a great man in every 
sense. He feels that the scopolamin-morphin 
method should be more known, more generally 
adopted, and it should be written about so that 
mothers may have an opportunity of knowing that 
there is a safe method which can insure them relief 
from suffering. He told me with great delight that 
only two weeks before he had received a letter from 
a man in Johannesburg, Africa, who is engaged in 
writing just such a book as this for mothers and he 
said, " I'm glad the matter is being given publicity ; 
the women should know." 

Sir Halliday Croom does not believe in the ad- 
vantage of pain; he thinks it is to be deplored that 
women have had to suffer unrelieved agony in child- 
birth for so long. He added feelingly : " No man 
wants to suffer if he can help it. It is absurd not to 
avail ourselves of the wonderful developments of 
medical science and use every means to prevent suf- 
fering." He went on to say that, of course, scopo- 
lamin-morphin needs careful handling, just as chlo- 
roform or any other anesthetic does. There is the 



MY VISITS TO THE BRITISH DOCTORS 51 

same general prejudice against scopolamin to-day 
which originally greeted chloroform. 

He told of the first case of chloroform narcosis 
in the Edinburgh hospital, the patient died — might 
have dropped dead in the street anyway and prob- 
ably had a bad heart — but the death was of course 
attributed solely to chloroform and the consequent 
prejudice against its further use was only gradually 
overcome. Sir Halliday has long employed scopo- 
lamin-morphin with perfect success in private prac- 
tise, and he finds it entirely unnecessary to keep the 
mother under constant supervision. He leaves a 
competent nurse in charge, and is always within 
reach by telephone. " The old-fashioned idea that 
a practitioner must sit beside a woman during the 
entire period of labor was outrageous — indecent ! " 
He finds that the mothers have less exhaustion after 
the judicious use of scopolamin-morphin than with- 
out, but of course much depends on the nature of the 
labor. 

He does not believe in early rising and cannot see 
what object is attained by it. Most women, under 
the circumstances, are only too grateful and thank- 
ful to have a rest. If it be amongst the poor, a rest 
is the best thing for them; if among the rich, a 
rest from the rounds of gaiety and pleasure is ex- 



52 THE TRUTH ABOUT TWILIGHT SLEEP 

cellent for them. The plan of early rising has been 
tried in Edinburgh, but Sir Halliday Croom has 
never countenanced it in his service, for he could 
not bring himself to believe that women wanted it 
or that it was of any especial advantage to them. 
As I had noticed that he referred in his report to a 
tendency sometimes to after-birth hemorrhage, I 
inquired if he really considered this a drawback to 
the method. He replied that he had only had such 
cases reported to him ; personally he had never seen 
a case of post partum (after birth) hemorrhage 
caused by scopolamin-morphin. He does not find 
that these drugs prolong the birth process. 

Sir Halliday Croom considers the amnesia (or 
forget fulness of pain) the most remarkable feature 
of Twilight Sleep. He has also observed a curious 
abstract, extraneous sense of pain in some patients. 
One of his patients on being asked if she felt any 
pain replied : "I am perfectly comfortable, but 
some one in the next room is suffering." " The 
secret of success in the use of scopolamin-morphin," 
said Sir Halliday, " lies in not giving the first in- 
jection too early in the first stage of labor or too late 
in the second period." 

" This can easily be learned by experience, I sup- 
pose ? " 

" By common sense," he corrected, 



MY VISITS TO THE BRITISH DOCTORS 53 

" Do you think the Germans have carried the use 
of scopolamin-morphin to greater perfection than 
others?" 

"No" — the tone was emphatic. "Nowhere 
have these drugs been employed with greater skill 
and success than right here by the British doctors." 

" Do you think the method will be still further 
developed ? " 

" We can't go very much further, can we ? What 
more do we need?" asked Sir Halliday; then he 
added what should go on record as the final word 
of reassurance as to the value of Twilight Sleep : 

" With the proper use of scopolamin-morphin we 
can insure painlessness in childbirth without danger 
to either the mother or her child. A method which 
does this has, I should say, practically reached per- 
fection." 

In Dundee I saw Dr. Robert Cochrane Buist. 
Dr. Buist had read a paper before the meeting of the 
British Medical Association held at Sheffield in 
1908. It was interesting to find that not only was 
he continuing the use of the method in the ma- 
ternity department of the Dundee Royal Infirmary, 
but he tells me both he and several other doctors are 
employing scopolamin-morphin in general practise 
with success. Under the conditions of the work at 



54 THE TRUTH ABOUT TWILIGHT SLEEP 

the Dundee Maternity it has not been found pos- 
sible to continue a systematic record in a manner 
suitable for detailed report, but as Dr. Buist has, 
since 1907, employed scopolamin-morphin in all 
cases where the labor becomes distressing (unless 
this is within an expected two or three hours of de- 
livery), the accumulated number of cases must now 
be very great. 

Dr. Buist, I'm sorry to say, is not at all in sym- 
pathy with the efforts of mothers to bring about the 
general adoption of this method of painless child- 
birth. He thinks the mothers should leave this mat- 
ter entirely to the decision of the medical practi- 
tioners. He says the field of experiments is gradu- 
ally widening and sufficient publicity is being given 
the matter by the doctors themselves. After Dr. 
Buist read his report on sixty-five cases at Sheffield, 
many other doctors present at the meeting made 
subsequent experiments and their experiments will 
naturally lead in turn to others. 

In spite of this undoubted gradual growth of the 
method, I pointed out the still existing general igno- 
rance of mothers on the subject. I have not found 
one mother in a thousand in either England or Scot- 
land who has ever even heard of this method. 
Should they not be given a chance to know that they 
need not continue to suffer in childbirth? 



MY VISITS TO THE BRITISH DOCTORS 55 

The suffering of women in labor had been greatly 
overstated, said Dr. Buist, especially by the Ger- 
mans. Only hysterical or high-strung women 
needed relief in childbirth and then, when it came to 
a question of relieving the pain, " the selection of an 
anesthetic should be left entirely to the judgment of 
the doctor attending. ,, 

In an earlier generation it was the fashion to keep 
women in total ignorance of all physiological facts ; 
it was even considered indelicate for a woman to 
make any inquiries about the construction and func- 
tions of her body. It is only within the past thirty 
years that women have been permitted to state openly 
that they possess legs — our poor mothers walked 
around on two mysterious things known modestly as 
" limbs." 

Left in darkness by our parents about the beauti- 
ful truths of our body and the miraculous workings 
of nature within us, whereby creation was continued, 
the only information which we ever attained was 
gotten through vulgar channels, and that false 
knowledge was so tainted by obscenity that it bore 
no likeness whatever to the sacred beauty of the 
truths of life. 

In the old-fashioned days when women were 
merely the blindfolded guardians of the power of 
childbearing, they had no choice but to trust them- 



$6 THE TRUTH ABOUT TWILIGHT SLEEP 

selves without question in the hands of the all-wise 
physician, but that day is past and will return no 
more. Women have torn away the bandages of 
false modesty, they are no longer ashamed of their 
bodies, they want to know all the wondrous work- 
ings of nature, and they demand that they be taught 
how best to safeguard themselves as wives and 
mothers. 

When it comes to the supreme function of child- 
bearing, every woman should certainly have the 
choice of saying how she will have that child. If 
chloroform is unsat is factory and even dangerous in 
childbirth, a mother should have the privilege of re- 
questing that it be not used. If scopolamin-morphin 
is safe and insures amnesia, a mother should have 
the right to demand that her physician employ these 
drugs, and if he declines to do so she should feel no 
hesitation whatever in seeking another doctor who 
will. 

As much as I differ from Dr. Buist on the point 
of the mother's subjection to the doctor, I can only 
feel admiration for his splendid contribution to the 
relief of women by his constant use of scopolamin- 
morphin during the past seven years. He finds the 
only thing necessary to make the method a success 
in private practise is the employment of capable 
nurses to carry out instructions. In general, Dr. 



MY VISITS TO THE BRITISH DOCTORS 57 

Buist believes in early rising, and he finds that pa- 
tients treated with scopolamin-morphin are in a con- 
dition where early rising is not injurious. He has 
never observed any tendency to after-birth hemor- 
rhage. 

As for the children, they are only affected when 
the first injection is given within four hours of the 
birth. If the children show any signs of intoxica- 
tion he employs artificial means of restoration, but 
he added that he believes that " probably more 
trouble is taken than is really necessary." 

The Royal Infirmary of Dundee is a magnificent 
building looking much more like an imagined castle 
than the real castle which lies just below it — now 
used as a barracks for the soldiers (formerly the 
headquarters of the suffragettes). The Maternity 
• — a pleasant, red brick building immediately be- 
hind the main Infirmary — overlooks, from the 
heights on which it is located, the city of Dundee. 
The war has claimed many of the Dundee Mater- 
nity's doctors and they are at present rather short- 
handed, but I cannot imagine a more pleasant spot 
where mothers may go for their lying-in, especially 
when we realize that the Dundee doctors are not 
mere experimenters with the method of Twilight 
Sleep but they are men who have already had years 
of experience with the use of scopolamin-morphin. 



58 THE TRUTH ABOUT TWILIGHT SLEEP 

Twilight Sleep is now a part of the regular hos- 
pital routine in Dundee. 

Every woman physician whom I've ever met has 
been altogether adorable. The very fact that a 
woman undertakes the study of medicine indicates 
a great core of sympathy with suffering and an over- 
whelming desire to serve humanity. This is more 
essentially true of a woman doctor than a man, for 
woman's nature makes her peculiarly sensitive, and 
one cannot but realize all that a woman must over- 
come within herself when she takes up the study of 
medicine. 

Dr. Constance Long is one of the most sympa- 
thetic doctors whom I've ever met and I was not sur- 
prised to find that without any actual training in the 
method of Twilight Sleep, her intense desire to re- 
lieve women's agony in childbirth led her to read 
everything which she could find on the subject and 
then she just forged ahead and made her own ex- 
periments. Dr. Long is the president of the British 
Association of Registered Medical Women, and at 
a meeting held on the 7th of January, 1913, she read 
a most interesting paper on her use of scopolamin- 
morphin in private practise. 

I am filled with gratitude to Dr. Long for her sym- 
pathetic willingness to give me any information 



MY VISITS TO THE BRITISH DOCTORS 59 

which would be of service to mothers in their battle 
for painless childbirth. She has always believed in 
diminishing pain wherever it is possible, especially 
women's pain, and she, like Sir Halliday Croom, 
thinks all women should be given every chance to 
know that there is this method of painless child- 
birth. 

As so many Continental obstetricians still lay 
stress on the fact that Twilight Sleep is not prac- 
tical in private practise, I was particularly anxious to 
find out the secret of Dr. Long's success with it in 
this field. 

" It consists in the employment of reliable nurses 
with whom one can entrust the patient after the 
first injection," said Dr. Long. She employs the 
Gauss memory test and calculates her dosage accord- 
ingly. The constant presence of the doctor is not 
at all necessary. The nurses often say they cannot 
see that the patient is in a condition differing in any 
way from the ordinary state of women in labor, and 
they are perfectly amazed to hear the mothers after- 
ward declare that they recall nothing of the process 
of birth after a certain period — indicating when the 
injections began to take effect. 

In spite of the normal appearance of the patient, 
Dr. Long always impresses the nurse with the fact 
that she must regard the patient-mother as under an 



60 THE TRUTH ABOUT TWILIGHT SLEEP 

anesthetic and accordingly keep the closest watch 
upon her. The patient is made to lie on her side, 
so there is no danger of the tongue falling backward. 
Though under the effect of the drugs, the mother is 
able to get up and attend to her bodily excretions as 
well as eat her meals regularly during prolonged 
labor. 

I asked Dr. Long if she believed in the custom of 
early rising, and she replied: 

" No. It is often the only chance in life the poor 
things have for an absolute rest." She generally 
keeps her patients in bed for about two weeks. 

All of Dr. Long's Twilight Sleep cases have been 
primiparce — women bearing their first child — and 
she has found that these mothers have absolutely no 
fear of future births, while on the other hand, where 
women have been delivered without Twilight Sleep 
and have suffered accordingly, she has often heard 
them say, " Never again." Dr. Long has had only 
one case in which the child was born sleepy. She 
declares she does not feel there is the slightest danger 
for the child in the method, and she has moreover 
never seen a case where she felt any alarm for the 
mother. She has known many instances where the 
mother simply could not have endured the birth 
without scopolamin-morphin. 

In one case of very protracted labor, because of the 



MY VISITS TO THE BRITISH DOCTORS 61 

patient's small, round pelvis, the mother would have 
suffered unspeakable torture without Twilight Sleep, 
but as a result of the use of scopolamin-morphin the 
woman retained no memory of the fearful ordeal 
through which she had passed. 

Dr. Long's last words to me were memorable and, 
coming from a doctor, peculiarly impressive. 

" Only when women demand and demand that the 
doctors adopt this method will the doctors have to 
give in and meet the demand." 



IV 



To Mothers 



I WAS greatly puzzled to know how to present 
this subject to the mothers so that they might 
be placed in a position whereby they could make 
statements based on positive knowledge, instead of 
having to ask questions of their doctors. I know 
men as a rule have an idea that women can neither 
cope with nor find interest in technical figures and 
facts, but personally I regard this as a masculine 
injustice to the feminine mind. 

Where a woman is really interested in a subject 
that is of vital importance to her sex, she will take 
infinite trouble to gain the necessary information. 
In every woman lie the latent qualities of the stu- 
dent. Think of woman's capacity to study the de- 
tails of housewifery, of domestic economy, of the 
care of children ! Almost every woman in the world 
is an authority on all that is relative to her daily life. 

When it comes to anything as vital as painless 
childbirth, I do not think I am deluded when I be- 
lieve that all mothers will be just as keenly interested 

62 



TO MOTHERS 63 

in the subject from a scientific and medical point of 
view as the doctors themselves. 

Unless we mothers do study Twilight Sleep from 
the very beginning, following its development, the 
medical experiments, the failures and the successes, 
we can be in no position to decide whether we de- 
sire this method for ourselves and our fellow- 
mothers, and we shall be unprepared to argue the 
matter with authority if we wish to urge a general 
adoption of painless childbirth by the entire medical 
profession. 

Moreover, I have felt the great necessity of mak- 
ing this book technically irreproachable. Should 
any mother wish to show this volume to her doctor 
she must feel confident that she is not showing him 
a book based merely on mothers' experiences and 
testimony, or on the personal and weightless enthus- 
iasm of the author; she must know that this book 
contains all the voiced and written opinions on Twi- 
light Sleep of the doctors themselves. Unless we 
study the records of those physicians who have made 
experiments with scopolamin-morphin we shall be 
neither in a position to make correct statements our- 
selves nor to refute false statements of others based 
on their ignorance of facts. 

When I began to study Twilight Sleep I rather 
dreaded the technical difficulties of the subject, but 



64 THE TRUTH ABOUT TWILIGHT SLEEP 

the longer I have worked over the medical reports 
the more keenly interested have I become ; I am now 
hoping that my experience may be indicative of the 
interest which may develop in the minds of other 
mothers after they have determined not to be satis- 
fied with superficial information on the subject. We 
can't afford to be superficially informed where the 
bringing of children into the world and the safety of 
the mothers and the babies is concerned. 

I remember being almost terrified at first by the 
apparent alarmingness of Dr. Hocheisen's expe- 
rience with scopolamin-morphin. I then carefully 
studied Dr. Gauss's directions for producing Dam- 
merschlaf and reread the Hocheisen report and I 
soon saw how far afield Hocheisen had gone from 
the Gauss instructions, and I realized that the fault 
of the failure lay entirely with Hocheisen, not with 
the method at all. 

Suppose a doctor should say to you: "Don't 
talk to me about Twilight Sleep! Scopolamin is a 
dangerous poison and mothers treated with scopo- 
lamin-morphin always have hemorrhage, while the 
children are born intoxicated." If uninformed, 
you would probably be so terrified you would drop 
the thought of ever trying Twilight Sleep yourself 
and warn all other mothers against it. But sup- 
pose you were familiar with the papers of Dr. 




Twilight-Sleep children of Herr Hensler. possessor of the 

only house, hotel and postoffice of Posthalde in 

the Black Forest 



TO MOTHERS 65 

Gauss, the American report of Dr. Birchmore, the 
record of Sir Halliday Croom and all the others 
contained in this book, you would not be alarmed 
or influenced in the slightest, for you would in- 
stantly realize that the doctor who utters a whole- 
sale rejection and damnation of Twilight Sleep 
either knows nothing of the method from personal 
experience or else he speaks from personal failure 
caused by his own faulty technic. 

Every mother should be thoroughly conversant 
with all the experiments which have been made with 
scopolamin-morphin in order to safeguard herself 
from being misled or alarmed. Knowledge is not 
only the most impressive thing in the world ; it is the 
most powerful. I remember once hearing a Ber- 
mudian lady make an incorrect statement about the 
origin of the sago palm. A dear old gentleman 
gently corrected her. The lady disputed him and 
with some ire reiterated her first statement, not 
realizing that the man who had corrected her was a 
great natural scientist. He turned his wonderful, 
wise old eyes upon her and said : 

" Madame, / know." 

I have never heard anything in my life that 
sounded so convincing as those two short words. 
What a wonderful thing it is really to know! 
After you have followed the history of painless 



66 THE TRUTH ABOUT TWILIGHT SLEEP 

childbirth from its faulty beginning to its present 
perfection, if the subject of Twilight Sleep is to be 
considered, you will not be making incorrect state- 
ments or asking questions of others; you will be in 
a position to say, " I know." 



Gauss's First Publication on Twilight 
Sleep 

the origin and early use of scopolamin 

IN pursuing the study of scopolamin one finds 
that the discovery of its chemical qualities was 
made in Germany, and Germany has remained the 
nursery of scopolamin up to the present time. It 
has been in that small corner of Germany known as 
Baden that all the most important investigations of 
scopolamin have been made, and the final develop- 
ment of its use in obstetrical narcosis was made at 
the Ludwig Albrecht University of Freiburg in 
Baden. 

To find the actual debut of scopolamin we must 
go back to the year 1880, when Ladenburg found 
that the seed of a plant called Hyoscyamus niger, 
growing in all the waste places of Europe, Siberia, 
Caucasus, and Judea, contained besides hyoscyanin 
a second alkaloid which he called hyoscin. Ten 
years later, in 1890, Schmit experimenting with the 

67 



68 THE TRUTH ABOUT TWILIGHT SLEEP 

roots of Hyoscyamus niger procured the same crys- 
tals obtained by Ladenburg, and to these he gave the 
name of " scopolamin." 

The first pharmacological studies of scopolamin 
were made by Robert and his disciples, and after 
many experiments a decision was reached that hy- 
oscin and scopolamin were one and the same chem- 
ical. 

Since the beginning of the nineties, scopolamin 
has been largely used by the alienists and the eye 
specialists ; the latter employed it for the same pur- 
pose for which atropin had been used. It was found 
that it could be used for a longer time than atropin, 
had about five times the strength, and was without 
disagreeable side effects. 

Schneiderlin was the first alienist to experiment 
with scopolamin; these experiments were conducted 
in the insane asylum of Emmendingen near Frei- 
burg. He found it of inestimable value on account 
of its hypnotic quality in calming maniacal pa- 
tients. Bumke, a later alienist of Freiburg, found 
that scopolamin had no injurious effect on the spine, 
its effects being confined largely to the brain ; by its 
use the motor excitability of the insane patients 
could be diminished because of the drug's weakening 
effect on the central function of the brain. 

Steffen of the Royal Frauenklinik of Dresden, 



GAUSS'S FIRST PUBLICATION 69 

however, has been a severe critic of the use of scopo- 
lamin in insanity, saying: "In the case of incur- 
able insanity it may be administered, but as long as 
there is any hope to effect a cure, take care not to 
spoil the hope." 

It is still used in the insane clinic of Freiburg, 
in both curable and incurable cases, as a sedative for 
excitability of body, in the small hypodermic injec- 
tions of .0001 or .0005 g. ; larger doses are not 
avoided because of considered danger, but because 
the smaller dose has been found effective. 

Schneiderlin was so encouraged by the use of 
scopolamin upon the insane that he began experi- 
ments in 1900 with its use in surgery, with what he 
reported as success. 

Von Steinbuchel in 1903 then made the first at- 
tempt to use scopolamin for the reduction of pain 
in childbirth, aiming only to obtain a state of hypal- 
gesia * with a hypodermic dose of .0003-0004 g. 2 
scopolamin + .01 g. morphin. In his twenty cases 
Steinbuchel found a lessening of pain, no loss of 
consciousness, no weakening of labor, no intoxica- 
tion of child. 

1 Dr. Kronig's definition of hypalgesia is : "A state in 
which the patient is still fully conscious and the events and 
sufferings at birth act upon her with more or less diminished 
strength." 

2 g for gram. 1 gram = 15.432 grains. 



70 THE TRUTH ABOUT TWILIGHT SLEEP 

The next reports were from Wartapetian, who 
found that in fifty per cent, of new born infants un- 
der scopolamin-morphin there was a state of deep 
asphyxia, bujt in the mothers he found no danger 
or diminution of labor. His experiments were fol- 
lowed by those of Reining, who had practically the 
same result, with an added observation of delay in 
the birth process. Following these were publica- 
tions by Pankart, Zeffer, Weingarten, and Pisar- 
zewski, the latter two being very favorable. Wein- 
garten found besides the lessening of suffering that 
scopolamin regulated the labor, and the birth pro- 
cess was accelerated. Newell and Puschnig ob- 
served a disposition of the uterus to relax. 

While the opinion about the value of scopolamin 
in therapeutics was decidedly favorable, many 
critics now arose condemning the drug as extremely 
dangerous, scopolamin being at that time subject to 
great variability. To clear up the differences of 
opinion on the subject of its variability and physi- 
ological effect, the Pharmacological Institute at Jena 
made extended experiments to ascertain the effect 
of scopolamin on the animal organism. It was 
found to increase the pulse of cats and dogs. After 
the heart of a frog had been deadened it was revived 
by scopolamin. The drug caused at first an increase 



GAUSS'S FIRST PUBLICATION 71 

of the blood pressure, which however soon sub- 
sided, often sinking below the normal. Frogs 
placed on their backs and given an injection of 
scopolamin remained in that position with a weak- 
ened heart. Rabbits were extremely agitated after 
an injection of only .01 g. and had slow respiration. 
Dogs after an injection of .05 and .01 g. showed only 
a slight increase in the blood pressure. 

Later on (in 1909), C. M. Nicholson at the Amer- 
ican Medical Association at Chicago made known 
his results in experiments on various animals with 
scopolamin. Repeated injections caused no de- 
generation of heart, liver, or kidneys. As long as 
feeding was not interfered with, repeated injections 
did not influence the physical condition of animals. 
When a fatal dose was given, death was found to 
have been caused by congestion of the intestines. 

Sohrt and Bumke (to return to our earlier date), 
made experiments on themselves in order to ascer- 
tain the effect on the human body and the mind, and 
reported that after ten minutes they entered a state 
of irresistible drowsiness with heaviness of eyelids 
and a sensation of thirst; this condition was suc- 
ceeded by quiet, firm sleep. Klinke gave himself a 
dose of 24 m g- scopolamin and enjoyed frightful 
hallucinations and illusions. 



72 THE TRUTH ABOUT TWILIGHT SLEEP 

THE FIRST GREAT EXPERIMENTS WITH SCOPOLAMIN 
IN OBSTETRICS 

The interest, however, of all German medical fac- 
ulties was not concentrated on the use of this alkaloid 
in obstetrics until the experiments of Dr. Kronig 
and his assistant Gauss were in progress in the de- 
livery wards of the Freiburg Frauenklinik. Kronig 
had earlier begun investigations of the scopolamin- 
morphin narcosis while at the University of Jena in 
Saxe- Weimar, but these were taken up on a much 
larger scale at Freiburg. 

When Gauss made his first report on the use of 
scopolamin-morphin in childbirth, only four other 
clinics had at that time followed von Steinbuchel's 
example at his clinic at Graz, in adopting scopo- 
lamin-morphin narcosis for diminishing the pain of 
delivery, viz. : Jena, Giessen, Budapest, and Klagen- 
furt, and the results of only 225 cases had been pub- 
lished. 

To these Gauss was then able to add reports on 
500 cases conducted by him in the Freiburg Frauen- 
klinik confinement wards. 

WHAT IS NORMAL LABOR? 

In presenting his report, which was entirely 
unique, Gauss first remarked that it was a most 



GAUSS'S FIRST PUBLICATION 73 

singular fact that the greatest opposition to the use 
of any narcotic in childbirth had come from the 
Church. The second and less violent opposition had 
arisen in the medical profession from men who 
asked: " Is it justifiable to lessen by narcotics the 
suffering of a woman in perfectly normal labor? " 
Others had urged that the labor pains were physi- 
ological and that no one had a right to interfere with 
the normal course of natural phenomena. Pur- 
suing the subject, Gauss asks : 3 " But what is 
physiological, what is normal? Granted that a 
physically and psychically healthy woman of child- 
bearing age can survive the physiological pain of a 
normal birth by summoning all her bodily and 
mental vigor without injury to her body and mind 
— an older woman, bearing for the first time, whose 
soft parts offer a many times stronger resistance to 
an enlargement — a rachitical 4 woman, whose pel- 
vis requires an especial birth process and abnormal 
labor to render a spontaneous birth possible — a 
woman in labor with generally narrow pelvis in 
whom the physiological pain of pressure and con- 
tusion is still further increased in addition to the pro- 
tracted pathological course of the birth — is it cor- 

3 " Childbirths in Artificial Dammerschlaf," by Dr. Carl J. 
Gauss. Archiv fur Gynecology, Vol. 78. 

4 Affected with rickets. 



74 THE TRUTH ABOUT TWILIGHT SLEEP 

rect to talk also in these instances about the physi- 
ological pain as a natural phenomenon? " 

THE REQUIREMENTS DEMANDED OF SCOPOLAMIN- 
MORPHIN 

Gauss considered that the requirements of a per- 
fectly successful narcotic were: a reduction in the 
pain of the mother to a degree that should be per- 
ceptible to her as well as to the attendant physician ; 
there should be no disagreeable secondary effects, or, 
if any, they should not be injurious to the mother 
and their strength should not be out of proportion to 
the degree of alleviation of pain; there should be no 
attendant nausea or disturbance of the subjective 
state of the health of the mother; the progress of the 
birth should not be affected by an interference with 
the muscular action, the bearing down of the after- 
pain, or the functions when nursing and in puerperal 
involution; furthermore the child should not be in- 
jured during intra-uterine life or extra-uterine life 
either at the beginning of its life functions or in the 
course of its first weeks of life or later development. 

With these high requirements in view he began 
working very cautiously with the, as yet little under- 
stood, combination of morphin and scopolamin. At 
first he only gave injections when he deemed that a 
birth could at any time be terminated by an in- 



GAUSS'S FIRST PUBLICATION 75 

nocuous operation should either mother or child 
show injurious effects from the narcosis. In choos- 
ing his first cases Gauss did not experiment with any 
patients showing disposition to complications due to 
narrow pelvis, placenta previa, 5 or habitual disturb- 
ance of the placental period. 

THE FIRST EFFECT OF THE INJECTIONS 

In describing the effect of the injections upon the 
mothers, Gauss says: "The majority of the pa- 
tients impress one as being very sleepy, but other- 
wise quite normal. Every pain is accompanied by 
clearly perceptible if often only slight expressions of 
suffering. The pains and the accompanying suffer- 
ings are referred to and felt clearly as such. Every 
question is perhaps sleepily but nevertheless clearly 
answered. 

u In this stage nothing beyond the very pro- 
nounced weariness of the patient strikes the layman 
or even a medical man who is unaware that an in- 
jection has been given. So much more astonish- 
ing is it subsequently to learn that the patient, whom 
one believed to be completely conscious has, after 
the birth, not the slightest idea of what she has just 
gone through, or of the conversation held with 
her." 

5 Presentation of the afterbirth before the child. 



76 THE TRUTH ABOUT TWILIGHT SLEEP 



ORIGIN OF THE TERM DAMMERSCHLAF 

" Taking into consideration the principal symp- 
toms of this intentionally produced and peculiar con- 
dition, and also the difference in principle between 
it and the conditions of semi-narcosis, I consider 
myself entitled to speak of my method as an arti- 
ficial ' Dammerschlaf ' or a condition of Twilight 
Sleep." 

To achieve such a Dammerschlaf requires a 
trained staff and a constant supervision by a doctor. 

In semi-narcosis the perception of pain in the 
brain is hardly disturbed, but in consequence of 
scopolamin narcotization the centers of perception 
are so stupefied that apperception 6 of pain does not 
take place. In the first state of hypalgesia the pa- 
tient is still fully conscious, in the later state of 
apathetic unconsciousness, the patient reacts unwill- 
ingly or not at all — there are no sense impressions 
and the physiological reflections are extinguished. 

Between the capacity to perceive and observe, and 
a complete narcosis is a half-way house, and it is to 
this half-way house that Gauss gave the now famous 
name of " Dammerschlaf." 

Of this condition he says: "I have often seen 

6 That kind of perception in which the mind is conscious of 
the act of perceiving. 



GAUSS'S FIRST PUBLICATION 77 

the patient, after the last and successful ejection 
pain, sink back on the pillows with the sigh of re- 
lief: * Thank God, that is over with/ She had 
undoubtedly at the moment a clear perception of the 
birth which had taken place, and took also the great- 
est interest in the child, its sex, state of health, and 
crying. If, however, she were asked about ten or 
twenty minutes later some such question as, When 
her child was coming? she would reply that she 
didn't know, or that it wouldn't be much longer, or 
some other similar answer, showing that the fact of 
birth having taken place, although perfectly per- 
ceived, had yet not been included in the storehouse 
of memory. In other words — as the alienists say 
— it had been perceived but not apperceived." 

THE NERVOUS SYSTEM AND CHILDBIRTH 

" The fact that there is absolutely no memory of 
the exertions which, toward the end of the birth, be- 
come more and more frequent and intense, does 
away with that condition of mental exhaustion that 
we so frequently observe in protracted births. 

" It is well known how seriously the nervous sys- 
tem of a woman is or may be affected by a difficult 
birth which demands the exertion of the last rem- 
nant of her mental and bodily strength, and that 
such a birth, if a corresponding tendency already 



78 THE TRUTH ABOUT TWILIGHT SLEEP 

exists, might possibly give rise to a severe nerv- 
ous exhaustion in which the memory of the terrors 
of childbearing, and a fear of a repetition of them, 
may reduce a woman's capacity and embitter her 
whole life. 

" The army of suffering women who, although 
exhibiting no sign of definite disease of the organs 
of generation, yet go to consult the gynecologist be- 
cause they attribute their general nervous com- 
plaints (caused by the memories of childbearing) to 
this region, shows emphatically how extremely in- 
jurious to the nervous system a painful birth may 
be in an organism disposed to nervous weakness. 
How many women show an exhaustion and lassitude 
for days after an ordinary birth. It is perhaps due 
to the avoidance of this state of exhaustion that the 
women delivered under the influence of scopolamin- 
morphin almost always pass the first night after 
birth in a deep refreshing sleep which many women 
delivered in the ordinary manner cannot obtain al- 
though greatly in need of it. 

" The statement has often been made to me that 
a patient has never been so comfortable after a 
birth; I have also often repeatedly made the ob- 
servation that the women, in consequence of their 
loss of memory, believe that they have only been in 
labor for about a third of the real time; these facts 



GAUSS'S FIRST PUBLICATION 79 

can only confirm me in the belief that in the Dam- 
merschlaf we have efficacious means of doing away 
with the nervous sequelae of childbirth. ,, 

DETERMINING THE DOSE 

" The dosage is naturally entirely different from 
that employed in surgery. 

" In the first place, a woman in childbirth is in 
any case much more susceptible than usual to all 
narcotics, so that very small doses will suffice to 
produce the desired effect. In the second place, it 
is far from our intention to attain a deep narcosis ; 
we must, on the contrary, avoid this, as we insist 
on a condition in which the group of muscles which 
play the most important part in the work of birth — 
those which produce the straining action — shall 
retain their effectiveness, not only as regards their 
voluntary but also their involuntary action. 

" The object to be attained by the use of scopo- 
lamin-morphin Dammerschlaf in obstetrics is, in 
fact, nothing beyond a reduction of suffering, and 
that slight degree of clouding of the consciousness 
in which impressions are not apperceived by the pa- 
tient. 

" It is obvious that the dosage employed by me 
for the injections during all the period embraced 
by these five hundred births has not remained the 



80 THE TRUTH ABOUT TWILIGHT SLEEP 

same as that at first employed, as I, of course, in the 
first attempts went to work very cautiously and 
therefore had frequent failures because of the small 
doses initially employed. Encouraged, however, by 
my first successes, but not yet satisfied with the re- 
sults, I then tried larger doses and found that in 
most cases the stage of Dammerschlaf could be 
reached, and that in as short a time as one desired. 
But to produce this condition in a short time we 
had to pay the price of unpleasant accessory symp- 
toms and these I wished to avoid. 

" The use of scopolamin alone did not appear ad- 
visable, since, as has already been observed by 
alienists and pharmacologists, it occasions in many 
persons a condition of excitement. It seemed best 
therefore to use in addition to the scopolamin a suf- 
ficient but not too large quantity of morphin, so 
that the unpleasant attendant effects, whether of 
morphin or scopolamin, could be avoided without 
a diminution of the narcotic action." 

After experimenting with the chemical in vary- 
ing forms, age, origin, and manner of preparation, 
Gauss found that the powder supplied by Merck, St. 
Margarethan, and the tabloids from Boroughs Well- 
come were the most reliable to be gotten at that 
time. 7 After further experimentation he decided 

7 The invariable scopolamin of Professor Straub, known as 



GAUSS'S FIRST PUBLICATION 81 

that it was best to use separate solutions prepared by 
a pharmaceutical chemist .03 per cent, solution of 
crystal scopolamin hydrobromic in sterilized dis- 
tilled water and a one per cent, morphin muriaticum 
solution. As soon as the preparation showed signs 
of flakiness it was thrown away. The solution was 
kept in a dark, cool place. 

The variability in the effect of the drug he be- 
lieved at that time to be largely due to the varying 
susceptibility of different constitutions to scopo- 
lamin, and also the varying susceptibility of the 
same individual at different times to the same 
amount of injection. He found that the weight of 
mothers had something to do with the effect of the 
drug — tall, massively built women requiring a 
larger dose than short or slender ones. All organ- 
isms which had been deteriorated by illness, exhaus- 
tion, or anemia reacted in a greater extent to scopo- 
lamin-morphin. The habitual use of the alkaloid on 
patients made no difference in the action of the 
drug. 

THE AMOUNT OF SCOPOLAMIN-MORPHIN FOUND 
TO BE SUFFICIENT 

In order to feel his way, he preferred to make the 
initial injection a little too scanty rather than over- 

" Scopolia Haltbar," now used exclusively at the Frauenklinik, 
will be told of later on. 



82 THE TRUTH ABOUT TWILIGHT SLEEP 

generous. Beginning with a dose of .00045 g- t0 
.0006 g. scopolamin hydrobromic + .01 g. morphin, 
he found that in the case of average constitutions 
and susceptibility a good effect was obtained in from 
three-quarters of an hour to three hours. The 
scopolamin and morphin was used in separate solu- 
tions. If the desired effect was not then reached, 
a second injection of .00015 to .0003 g. scopolamin 
without morphin was given, which generally took 
effect in from a quarter of an hour to half an hour. 
The third injection was suited entirely to the condi- 
tion of the patient. If the patient had in the course 
of from two to four hours regained entire conscious- 
ness a repetition of the same second small dose with 
.005 g. morphin muriaticum added was found to 
be sufficient. 8 With this method of dosing Gauss 
found it possible to maintain a semi-narcosis extend- 
ing over several days, if necessary, without injuri- 
ous consequences. The largest total dose adminis- 
tered (extending over a period of forty-seven 
hpurs) was .00315 g. scopolamin to .025 g. mor- 
phin; in another case, extending over thirty-six 
hours, .0036 g. scopolamin was given alone. 

8 " The syringe used should be sterilized shortly before use 
and be as far as possible freed from the disinfecting liquid, as 
otherwise contamination of the solution cannot be avoided ; 
during the course of the birth the syringe must be kept in abso- 
lute alcohol in a glass vessel." — Gauss. 






GAUSS'S FIRST PUBLICATION 83 

In a later case (which has been severely criticized 
by several obstetricians) Gauss kept a patient of 
thirty-six years of age bearing her first child, fifty- 
seven hours under scopolamin-morphin, and eventu- 
ally accomplished a spontaneous birth in spite of the 
soft parts of the mother being rigid; there was a 
premature bursting of the membrane and the child 
was abnormally large. The mother retained no 
memory of her entire childbed, and the child was 
born active and lusty. Of this case Steffen says: 
" To keep a patient fifty-seven hours under narcosis 
made a total dose of .00375 g. scopolamin + .03 g. 
morphin. We have not the courage." 

INDICATIONS OF THE DEPTH OF NARCOSIS 

" The problem of maintaining the uninterrupted 
action of scopolamin-morphin," says Gauss, " is 
more difficult than that of inducing it. The most 
obvious way would be to deduce the narcotic action 
from the signs of pain shown by the patient. But 
these exhibitions of pain only cease entirely in a very 
small proportion of the cases, and besides this they 
also increase physiologically, even in Dammerschlaf, 
toward the end of the birth, so that for these reasons 
they afford no reliable clues to the extent to which 
the consciousness is clouded. 

" The dilatation of the pupils of the eye in re- 



84 THE TRUTH ABOUT TWILIGHT SLEEP 

sponse to bodily pain takes place, as I was able 
regularly to ascertain, also in response to a birth 
pain, and is greater the more acutely the patient is 
conscious of the sensation of pain. The pupils of 
some patients become greatly dilated in consequence 
of the preponderation of the action of the scopo- 
lamine Gauss concludes that the action of the 
pupillary reflexes cannot be regarded as an absolute 
indication of the extent to which consciousness has 
lapsed. Neither can coordination be counted on as 
a safe test. 

" As the Dammerschlaf begins, the locomotor co- 
ordination becomes worse and worse, and when the 
narcotic action has reached its highest point it is al- 
most entirely absent." 

ORIGIN OF THE " MEMORY TEST " 

It is of great importance to follow Gauss care- 
fully on the subject of consciousness and memory, 
because it is necessary to have a perfect understand- 
ing of the basis of his memory test in order to ap- 
preciate his reasons for adopting this test as the 
guide to dosage. Moreover, the importance of the 
memory test as a criterion is proven by the fact that 
many of the failures of other obstetricians with the 
Dammerschlaf can be traced to the fact that the 
memory test was not strictly observed and conse- 



GAUSS'S FIRST PUBLICATION 85 

quent relative overdosing of patients followed. 

"After trying all sorts of things," says Gauss, 
" I was put on the right track by considerations of 
the views current amongst alienists. The stage of 
scopolamin-morphin action which we wish to attain 
is only a derangement of the consciousness. 

" What we term consciousness is the sum total 
of the simultaneous mental processes into which in- 
ternal and external stimuli are transformed. De- 
rangements of the consciousness are consequently 
pathological deviations from the regular course of 
these mental processes which can exhibit various de- 
grees of clearness according to the magnitude of the 
liminal value. 

" Weakness of memory consists of a diminution 
or loss of the capacity for remembering past impres- 
sions; derangement of the perception is character- 
ized by limitation of the formation of new memory 
pictures or images. In the amnesia produced by 
scopolamin-morphin the retention of already formed 
memory-pictures and concepts is not affected, but 
only the formation of new ones. It must conse- 
quently be also conversely possible, by testing the 
capacity of perception, to arrive at conclusions as to 
the subsequently appearing forget fulness and so as 
to the intensity of the action of the drug at the 
moment. 



86 THE TRUTH ABOUT TWILIGHT SLEEP 

" My expectations of the truth of this theory were 
confirmed by my experiments. 

" Since that time I have guided myself as to the 
dosing almost altogether according to the varia- 
tions of the carefully tested capacity of apperception 
and have, when these tests have been properly car- 
ried out, never been misled." 

For the successful attainment and maintenance of 
Dammerschlaf, Gauss has insisted (from the time 
of this first published report on 500 cases up to the 
last published report on 3,000, and now verbally 
after experience in over 6,000 cases) that there is 
but one guide for the physician — the " memory 
test." This memory test has also been subjected to 
much criticism by his opponents, Steffen of Dres- 
den, Bumm and Hocheisen of Berlin, and Gminder 
of Essen. 

HOW TO CONDUCT THE MEMORY TEST 

The very simple method of the memory test, to 
quote Kronig, is as follows : " No testing of the 
power of perception begins until half an hour after 
the second administration of scopolamin-morphin 
by a subcutaneous injection. Some object is then 
shown the patient and she is asked to observe it. 
Some time after it is shown to her again ; if she re- 
calls having seen it before, it is considered as an in- 



GAUSS'S FIRST PUBLICATION 87 

dication that a third dose of the same quantity as 
the second is required, as no clouded consciousness 
has as yet been established. Objects chosen for ob- 
servation are generally those which have some con- 
nection with the process of birth, and are conse- 
quently sufficiently well known to patients not to be 
too striking. Very often a patient is merely cate- 
chized on the number of injections which she has 
had; if she can recall the number it is a proof that 
no Dammerschlaf as yet exists. It certainly re- 
quires practise and experience to decide how best to 
test the condition of consciousness of particular pa- 
tients in accordance with their intelligence. After 
a state of clouded consciousness has been established 
no further injection is given until the power of per- 
ception in patient recognizes an object shown half 
an hour previously. In the case of all but the first 
injection scopolamin alone is generally adminis- 
tered." 

StefTen remarks concerning this memory test 
that, " the power of -observation varies much in the 
wide-awake state of individuals and more so in pa- 
tients under the variable influence of scopolamin. 
Entirely dominated by their expectation of an event 
which will mean joy or sorrow for them they have 
slight attention to give to objects shown them by 
the physician, so that their memory of these articles 



88 THE TRUTH ABOUT TWILIGHT SLEEP 

disappears rapidly. Probably every one has had 
the experience that he has heard a question and an- 
swered it, while he was actively occupied with some- 
thing else, so that he recalled only indistinctly the 
question or forgot it entirely. It is equally diffi- 
cult for a physician to make correct observations of 
the memory sense in patients without having had ex- 
perience as an alienist. It is evident that various 
observers will arrive at varying quantities and con- 
clusions." 

Gauss maintains (and has his undoubted success 
to support him) that the memory test is simple, re- 
liable, and the only guide to the observer, for the 
reason that the regularly recurring labor pains can- 
not be used as tests; they always recur and there- 
fore make each time a more lasting impression on 
the memory. The complaints of mothers are even 
less to be counted on as a guide, as they are solely 
based on the perception not apperception, and after 
birth, however much complained about at time of 
occurrence, are not recalled at all. It is also evi- 
dent that the names of objects shown will accum- 
ulate during the course of process and therefore 
it will become gradually more and more difficult for 
the doctor to keep his bearings. 

In order to control all symptoms correctly they 
have at the Frauenklinik a so-called " Scopolamin 



GAUSS'S FIRST PUBLICATION 89 

Curve" which is filled out from each case by the 
nurse. This is the form of the curve : 

Date: 

Time: 

Injection (place, quantity, manufacturer of scopolamin, 
symptoms) : 

Subjective statements of patients about fatigue, thirst, 
pain in small of back? in the abdomen? at peri- 
neum: 

Objective observations about sleep (during intervals be- 
tween pains, or during pains, twitching of hands, 
color of face, effect of suffering, consciousness) : 

Progress of birth : examination, operation, bursting of 
amnion, the first contraction of abdomen, entering 
of head, and passing of head) : 

Pains, how often? 

Pains, how long? 

Pains, how vigorous? 

Heart sounds: 

Pulse : 

Breathing : 

Temperature : 

As will be seen, all factors of importance to birth 
and Dammerschlaf are considered in this diagram, 
so that a properly-filled-out diagram is the best 
proof for correctly observed birth and the dosage, 
and in the compilations of statistics. 



90 THE TRUTH ABOUT TWILIGHT SLEEP 

THE CONSTANT PRESENCE OF THE PHYSICIAN 
NECESSARY 

Gauss insists that an uninterrupted watching of 
the patient is an unavoidable necessity for the proper 
maintenance of the Dammerschlaf and a sufficient, 
yet uninjurious, dosage. " If this is not done," he 
says, " the result is either overdosing, in which case 
unpleasant side effects occur, or in underdosing 
when as a consequence the Dammerschlaf is inter- 
rupted and the patients retain in their memories 
events and observations made during isolated lucid 
intervals in the course of a more or less protracted 
period of amnesia. The existence of such " memory 
islands " — as I term them — is extremely injurious 
to the total effect; the patient connects them with 
one another by natural trains of thought and so 
forms for herself a picture of the birth that, pre- 
cisely because it is based upon isolated but exact 
observations, gives her so much more the idea of 
having a genuine recollection of the course of the 
birth. 

" It is clear that the accurate checking of the in- 
tensity of the action of scopolamin-morphin will not 
be so very easy. Curiously enough it is most diffi- 
cult in the case of extremely demented and of 
highly intellectual women. Unless the doctor and 



GAUSS'S FIRST PUBLICATION 91 

a skilful, well trained and experienced obstetric 
nurse keep a close observation on the whole course 
of the birth, nothing but repeated failures are to be 
looked for in the general results." 

PRESERVING THE PATIENT FROM DISTURBING IM- 
PRESSIONS 

" The patient should as far as possible be shielded 
from all stimulation, mental and physical. It is 
consequently best to have her in a room by herself, 
where nothing disturbs the quiet beyond the pro- 
ceedings necessary for the birth. Loud conversa- 
tions, penetrating noises, the coming and going of 
relatives — in short, everything that sets the pa- 
tient's senses to work — should be carefully avoided. 

" As we often found the only thing observed by 
the mother was the crying of the new-born infant, 
we have now made it a custom to carry the child 
out of hearing of the mother as quickly as possible. 

" We have reduced the stimulation of the sense 
of hearing by the use of antiphones or balls of 
cotton wool dipped in oil and put into the ears. 

" The sudden turning on of the electric arc light 
in our obstetric operating room often had a dis- 
turbing effect and was sometimes the cause of in- 
opportune awakening, so we now protect the eyes 
by a dark colored cloth or colored spectacles and 



92 THE TRUTH ABOUT TWILIGHT SLEEP 

have found that this greatly facilitates the main- 
tenance of an uninterrupted Dammerschlaf." 

SUBJECTIVE EFFECTS OF SCOPOLAMIN 

Among the subjective effects of scopolamin he 
mentions thirst, which is due to the effect of the 
drug on the secretions of the mucous membranes. 

Gauss says : " I never hesitate to give the pa- 
tient as much water as she desires and in spite of 
this I have never seen any injurious results follow. 
Vomiting is hardly ever observed, unless it has al- 
ready appeared before the injections are begun." 

Among other side effects, derangements of the 
senses of sight and hearing now and then occur. 
The patients sometimes answer questions which no 
one has asked them, and again they will carry on 
whole conversations with themselves. Mental hal- 
lucinations occasionally occur. " But," says Gauss, 
" these hallucinations only occur in stages of un- 
intentionally profound derangement of the con- 
sciousness and as the patient cannot afterwards 
remember them, they cannot be said to affect her 
subjective comfort." 

EFFECT OF SCOPOLAMIN-MORPHIN ON THE 
LABOR PAINS 

In order to ascertain the effect of scopolamin- 
morphin on the satisfactory working of the eject- 



GAUSS'S FIRST PUBLICATION 93 

ing forces — that is to say, the labor pains and the 
straining action — Gauss' assistant, Dr. Schlimpert, 
made what was called a " Birth-pang Curve," based 
on his exact checking of the pangs by recording and 
registering them in curves. Schlimpert registered 
the interval of time between a pang and the previ- 
ous one and how long each pang lasted. It was 
found that the higher the " pang mountains," the 
less the frequency of the pangs; the broader the 
" mountains," the more powerful the action of the 
individual pain. 

The pains were never judged by the signs of suf- 
fering given by the patient but by the contractions 
observed by the hand of an obstetric nurse kept 
continuously on the uterus. 

Schlimpert's laborious work of observation (128 
pang curves) were added to by critical notes made 
by Gauss and entered at the conclusion of every 
birth. 

Poor young Schlimpert gave his life for this 
work. For many months he had been suffering 
from what he recognized as appendicitis, but so 
interested was he in the Dammerschlaf and his 
especial task of helping to prove by his " curves " 
that scopolamin-morphin did not affect the labor 
pains unfavorably, he kept the secret of his suffer- 
ing from all his associates in the clinic; it was not 



94 THE TRUTH ABOUT TWILIGHT SLEEP 

until the pain became at last unendurable, did he 
confess the truth to Kronig and Gauss. It was too 
late. Dr. Schlimpert survived the operation only 
a few days, but the courage and beauty of his last 
days will never be forgotten in the Frauenklinik. 

In addition to Schlimpert's work, Gauss also had 
notes of the pang action in 493 cases. In 103 
cases the pangs were excellent, in 273 good, in 36 
varying, in 39 bad from the beginning. In 451 
births no noticeable affection of labor action by the 
injections could be detected. In 42 cases an alter- 
ation in the pang was observed, in 36 cases they 
were decidedly improved by the injections, in 8 
cases they became worse. 

How far the alteration in these last eight cases 
was due to the drug and how far to chance, Gauss 
found it very difficult to ascertain. 

On the whole, he felt that the result of the 
" curves " proved there was practically no question 
of an unfavorable action by the scopolamin-mor- 
phin injections on the labor pangs. 

" A bystander often observes what he considers 
a diminution of the power of the pains after the 
injection, because there is a diminution or cessation 
of demonstrations of pain on the part of the pa- 
tient, but by placing the hand on the uterus it is 
found that the processes of birth are continuing un- 



GAUSS'S FIRST PUBLICATION 95 

changed although there may be no outward sign 
of intense suffering." 

According to Schlimpert's calculations there was 
sometimes an increase of time between the pains, 
but on these occasions he also observed an increase 
in the duration of the pangs ; furthermore he found 
that the injections had a clearly recognizable regu- 
lative effect on previously irregular labor action. 
Schlimpert's tables also proved that the reflex 
straining action in most cases was good. 

Gauss says the lesson to be learned from a study 
of these " curves " is first : not to give too large 
quantities of scopolamin-morphin at one time. 
Begin with relatively small doses, then by gradu- 
ally adding to them you induce the desired action, 
so to speak, surreptitiously. Larger quantities, ad- 
ministered in a limited time, bring about a more 
rapid effect, but they also often — though not al- 
ways — have an undesirable effect on the labor 
action. 

"Secondly: the quantity of morphin introduced 
into the body must be kept as small as the desired 
narcotic effect permits." 

THE AFTER-BIRTH PERIOD 

He found that if there was no appreciable 
diminution of the pang action during Dammer- 



96 THE TRUTH ABOUT TWILIGHT SLEEP 

schlaf there would be none in the after-birth 
period either. " Under all circumstances — hem- 
orrhage of course excepted — the spontaneous de- 
tachment of the placenta" (after-birth) "is 
awaited; if the expulsion has not taken place spon- 
taneously it is left to the straining action of the 
patient or facilitated by gentle pressure on the ab- 
domen, not on the uterus." 



EFFECT OF SCOPOLAMIN-MORPHIN ON THE 
MILK SECRETION 

Although, as Gauss has pointed out, scopolamin 
affects the glands and mucous membranes, it has 
not been found to affect the milk secretion. 

As a test of this, statistics were kept of two hun- 
dred mothers delivered without scopolamin-morphin 
and like statistics were kept during the same period 
of two hundred Dammerschlaf mothers. 

Here is the table: 



Without 
scopolamin. 
137 = 68.5% 

8= 4% 

55 = 27.5% 



With scopolamin. 

134 = 67% had large milk supply. 

15= 7.5% had insufficient milk supply. 

51=25.5% had no milk at all. 



DAMMERSCHLAF AND THE CHILD 

As to the effect on the child, Gauss says he is 
absolutely convinced "'of the innocuousness of the 



GAUSS'S FIRST PUBLICATION 97 

Dammerschlaf. This confidence is shown by the 
rule now invariably followed of beginning the in- 
jections as soon as the pains occur at regular inter- 
vals and are found to be unpleasantly painful by 
the patient, without any regard for the stage which 
the birth may have reached or the complications 
that may be present." 

Of the 506 children born to these 500 mothers, 
500 (98.8 per cent.) were born alive and 6 (1.2 
per cent.) were stillborn. Of these 500, 316 (62.2 
per cent.) were vigorous and lusty; 199 (23.8 per 
cent. ) showed, on the other hand, a condition which 
indicated that the injections had affected the child's 
organism. 



Gauss had already added the term " Dammer- 
schlaf " to the medical lexicon; he now added an- 
other word to describe the above condition of the 
child affected by scopolamin — that term is " oli- 
gopnea." 

It is a condition of intoxication evidenced by the 
child; after taking a deep breath at the moment of 
birth with a more or less loud cry it relapses into a 
motionless condition, the heart action however 
continuing. It opens its eyes only to close them 
again as if tired. 



98 THE TRUTH ABOUT TWILIGHT SLEEP 

" In my earlier cases," says Gauss, " this condi- 
tion inspired me with great uneasiness and I con- 
sidered myself bound immediately to commence 
measures for resuscitation. Gradually, however, 
by cautiously delaying my intervention, in suitable 
cases, I found this anxiety was exaggerated, so I 
then calmly waited to see whether the child would 
begin to breathe properly without outside interven- 
tion and I found that various infants left alone 
from fifteen to twenty minutes established regular 
breathing, the action of respiration becoming more 
frequent until normal breathing was established." 

In cases where it seemed advisable to give the 
child assistance, it was found that the quickest and 
surest method of resuscitation was a rhythmic mas- 
sage of the heart. Often a slight irritation of the 
child's skin is sufficient to produce regular deep 
breathing and loud crying. 

The effect of artificial resuscitation upon the 
child, Gauss compares to a fly-wheel which once 
set in motion is kept indefinitely in motion by small 
regularly acting forces, which however would not 
have been sufficient to start it. 

He says : " While I do not believe this intoxi- 
cated condition harbors any serious dangers to the 
organism, I have nevertheless tried to avoid it by 
modifying the dosage. As I applied the first doses 



GAUSS'S FIRST PUBLICATION 99 

of scopolamin-morphin without knowledge of the 
effect to be expected in general, overdosages were 
unavoidable. Only by degrees I then learnt the 
objectionable effect of superfluous quantities of 
morphin which undoubtedly increased the early 
number of oligopneic children." 

Kronig reports that at first they had 20 per cent, 
oligopneic children, a record which by the year 
1908 was reduced to 10 per cent. The mortality 
of children at the Frauenklinik during or soon after 
birth has been decreased considerably since the in- 
auguration of the Dammerschlaf. " We have had, 
for example," says Kronig, " in the last 500 deliv- 
eries under scopolamin, only one child to mourn. 
For this strikingly low mortality Professor AschofT 
has offered perhaps the right explanation, viz. : 
that the slight narcotization of the respiratory 
organs during birth, by extremely minute quantities 
of scopolamin, is advantageous to the child. If the 
child, in the interruption in the placental supply of 
oxygen responds by a premature respiratory move- 
ment, permanent obstruction of the air passages by 
inhalation of amniotic fluid 9 with epithelium 10 
and vaginal bacteria takes place. If, on the other 
hand, the child is slightly narcotized by scopolamin 

9 The fluid in the sac directly encircling the unborn child. 

10 The outermost bloodless layer of the mucous membrane. 



ioo THE TRUTH ABOUT TWILIGHT SLEEP 

it does not immediately respond to the small ac- 
cumulation of carbonic acid in the blood and the 
air passages remain free." 

LATER STATE OF INFANT'S HEALTH 

" From our investigation of the children of pri- 
vate patients, who can easily be kept track of, we 
have found that within the first year there can be 
no talk about an injury to the development of the 
children on account of the employment of scopola- 
min-morphin.' , 

AFTER-HEALTH OF MOTHER 

As for the Dammerschlaf affecting the later 
health of the mother, I recall one case of a Freiburg 
mother, who, six months after having had her first 
child at the Frauenklinik, had an attack of some 
slight nervous disorder; her condition was immedi- 
ately attributed to Twilight Sleep by relatives, 
friends, and a Freiburg general practitioner. The 
mother, eventually convinced that scopolamin was 
to blame, went to see Dr. Kronig about the matter, 
and this is the reply she received from him : 

" As well say you have sneezed in June because 
you sat in a draft on Christmas Day." 



VI 

The Famous Hocheisen-Gauss Controversy 

AS a result of the sensation produced in the 
Continental medical world by the publication 
of this Gauss report, many of the head physicians of 
the large European hospitals gave orders that the 
" Gauss Dammerschlaf " was to be given a trial by 
their staff. The reports on these experiments pub- 
lished in the German and Austrian medical jour- 
nals of the following year make very interesting, 
exciting, amusing, and terrifying literature. 

The most important experiment was that con- 
ducted at the Berlin Charite by order of Geheim- 
rath Bumm. As Bumm stood virtually at the head 
of the entire German medical world, his support or 
condemnation of Twilight Sleep was a matter of 
tremendous importance. 

The results of the experiments at the Berlin 
Charite were reported upon by Herr Bumm's as- 
sistants — Hocheisen and von Bardeleben — at the 
meeting of the Society for Obstetrical Practise and 
Gynecology at Berlin in 1906. This was an epoch- 

101 



102 THE TRUTH ABOUT TWILIGHT SLEEP 

making meeting, for it was to this meeting that 
Gauss — then just emerging from his twenties — 
went to break a lance for his method in the face of 
an expected tremendous battery of opposition. It 
was very like a David and Goliath performance — 
Gauss's David to the triplet Goliath of Bumm, 
Hocheisen, and von Bardeleben. 

The discussion at this meeting has been handed 
down in the German medical world as the 
" Hocheisen-Gauss Controversy." Because of the 
importance still given to this discussion in the Ger- 
man medical publications of to-day, I shall give a 
detailed account of the reports of Hocheisen and 
von Bardeleben. There is one peculiarly important 
feature of both these reports to which I would like 
to draw your especial attention: neither Hocheisen 
nor von Bardeleben ever refer in any way, in their 
reports, to the memory test. Yet Gauss had clearly 
stated it to be the very backbone of his Dammer- 
schlaf. 

Hocheisen's opening words are : " It is surpris- 
ing to hear scopolamin praised when it is known to 
be one of the most dangerous of all poisons — a 
poison incalculable in its action." As Gauss after- 
wards said, " That theory Hocheisen uses as the 
motto for his discussion." * 

i Munchener Med. Wochenschr., 1907. 



HOCHEISEN-GAUSS CONTROVERSY 103 

"We have treated all told from 120 to 130 
cases," says Hocheisen. 2 " One-half of the births 
were attended by von Bardeleben — the other half 
by me. I will only report on the last continuous 
series of 100 cases." 

After claiming : " We have always observed the 
instructions of Gauss," immediately after we find 
Hocheisen saying: "From the beginning we used 
smaller doses. We only gave the injection when 
the head was found to be entering the pelvis. We 
used little or no morphin." A little further on we 
find : " The precautionary measure recommended 
by Gauss of keeping the patients separate could not 
be followed by us. Patients awaken very easily 
from the Dammerschlaf and the slightest noise dis- 
turbs them. The seclusion, therefore, is probably 
recommendable but in practise I believe it will be 
found very difficult to attain. 

" On the whole," Hocheisen acknowledges, " we 
must state that in a large percentage of patients 
small doses of scopolamin reduced the suffering. 
In 70 per cent, there were secondary effects. 
When falling to sleep the patient gets very red in 
the face, the redness sometimes increasing to purple. 
There is a pronounced thirst in 45 per cent. We 

2 From. Miinchener Medical Wochenschrift, No. 37, 1906, 
and Ztschr. f. Geburtsh, u. Gynak, Stuttgart, 1907. 



104 THE TRUTH ABOUT TWILIGHT SLEEP 

had six cases of vomiting. Four patients were so 
delirious we had to use morphin. In 46 instances 
labor was not influenced, it was sometimes even 
stimulated; 21 times it was considerably weakened; 
15 times labor was retarded during period of ex- 
pulsion; 3 times it ceased entirely. In 24 per cent, 
of the cases we observed a decided influence upon 
the abdominal action." 

We find, therefore, by the above Hocheisen 
figures that in the majority of cases (46) the labor 
action was bettered by scopolamin — in 39 instances 
it was affected unfavorably; that leaves 15 cases 
out of the hundred on which Hocheisen keeps silent, 
so one must infer that in these 15 cases labor was 
not affected either one way or the other. If there 
was a decided effect on the abdominal action in 24 
per cent, of cases, that leaves a majority of j6 cases 
where the action was not affected. 

" In the sixty births observed by me," says 
Hocheisen, " I have not used the forceps in a single 
case. Among von Bardeleben's cases the forceps 
were used six times on account of the condition of 
the child." 

It seems surprising and a bit inconsistent after 
Hocheisen has said he did not have occasion to use 
the forceps at all, to find him immediately after 
making this assertion : " But I believe in practical 



HOCHEISEN-GAUSS CONTROVERSY 105 

obstetrics, with the use of scopolamin — forceps 
will have to be employed in from 20 to 25 per cent, 
of all cases." 

From Bumm's data we find him to state that an 
average birth lasts twelve and one-half hours with 
a period of expulsion of one hour and three- 
quarters. 

Says Hocheisen : " With our scopolamin cases 
the expulsion period averaged six hours and fifteen 
minutes against the normal one hour and three- 
quarters. The shortest length of birth was fifteen 
minutes, the longest seventy-nine hours. In some 
cases the placenta expulsion took three hours. 

"Under scopolamin we had 15 per cent, where 
after nine days the uterus was still the size of a 
child's head. This is probably no accident, consid- 
ering the disturbances arising from scopolamin dur- 
ing the placental period." 

Hocheisen then gives a very detailed account of 
the case of a girl of nineteen bearing her first child. 

" Before the injections," he says, " I had exam- 
ined the heart but only superficially I admit. I 
gave her injections of .0005 g. scopolamin and .01 
g. morphin. The patient at once became very rest- 
less at each pain, her restlessness increasing to such 
an extent that after five hours I gave her another 
injection of .005 g. morphin. The birth occurred 



106 THE TRUTH ABOUT TWILIGHT SLEEP 

two hours later without complications. One hour 
and a half after delivery the patient sat up suddenly 
in bed and could not get her breath, becoming blue 
in the face. Her pulse was still 80 — good vigor- 
ous beats — but it suddenly rose to 120. There 
was a complete perturbation of heart. After one 
hour I gave morphin, whereupon her condition im- 
proved, but it was not until late that night that the 
patient was out of danger. The following day she 
was in a comparatively good condition." 

In one case of pronounced dyspnea (difficult 
breathing) and a case of violent breast pang 
Hocheisen lays the charge to scopolamin, though in 
the last case two similar attacks had already oc- 
curred and an examination disclosed an affection of 
the mitral valve. 3 

" In 20 per cent, of all cases I observed a slack- 
ening of pulse and irregularities. 

" Gauss says the only counter indications for the 
use of scopolamin are primary weakness of labor, 
feverish condition, anemia, and somnolent condition 
without eclampsia " (convulsions during childbirth) . 
" I would like to add to these counter indications, 
diseases of the heart and kidneys, and any disar- 
rangement of the respiratory or circulatory system.'* 

3 The valve of the heart between the left auricle and the 
left ventricle. 



HOCHEISEN-GAUSS CONTROVERSY 107 

" What about the child ? " asks Hocheisen. " We 
have had one case of oligopnea which lasted for 
three-quarters of an hour. Gauss states that this 
condition passes off spontaneously, only a slight 
tickling of the skin or heart massage being sufficient 
for restoration. I do not believe it correct to think 
lightly of such a condition. We had 18 per cent, 
oligopneic children, and it cannot be attributed to 
morphin as we gave but little morphin. If the con- 
dition is due to morphin, the children would not 
react so quickly upon irritation of the skin, as they 
do. In addition to oligopnea, Gauss observed 13 
per cent, asphyxiated children. We had 15 per 
cent. This also has to be put down without further 
ado to scopolamin. Scopolamin causes protraction 
of birth and protraction of birth causes asphyxia." 

Hocheisen fails to mention that asphyxia often 
occurs without scopolamin, because of the entangle- 
ment of cord about the child's neck and from the 
aspiration by child of the amniotic fluid; that the 
latter was undoubtedly to blame in some cases is 
proven by the fact that he states, " four of these 
asphyxiated children had bronchitis " — a most usual 
result of amniotic fluid in the bronchial tubes. 

" One child," he says, " died one hour and a 
quarter after birth; postmortem showed a disease 
of the blood. This case cannot be wholly blamed 



108 THE TRUTH ABOUT TWILIGHT SLEEP 

on scopolamin." One wonders in what way it 
could be blamed at all ! 

" Another especially oligopneic child died after 
four hours; postmortem showed lungs to have been 
affected as the child aspired a quantity of amniotic 
fluid. The child had been delivered by forceps." 
After this account we are scarcely prepared to find 
Hocheisen declaring : " Indirectly, this death was 
certainly the effect of scopolamin." 

In summing up, Hocheisen says : " In our ioo 
cases of normal, uncomplicated births under sco- 
polamin we had 18 downright negative results and 
21 cases of mediocre effect." 

Hocheisen ends his report by declaiming dra- 
matically : 

" Away with the Dammerschlaf ! " 

Before we proceed with the report of von Bar- 
deleben given at this meeting immediately after 
Hocheisen's, I would like to give a few quotations 
from medical men on the Hocheisen report. 

R. C. Buist, gynecologist of the Royal Infirmary 
of Dundee, says in the Scotch and English Medical 
Journal of July, 1907 : " In their critical papers 
Hocheisen and Steffen 4 have assembled all the in- 
formation they could lay hands on as to the dele- 

4 The Steffen report will be given in a later chapter.— 
H. R. V. 






HOCHEISEN-GAUSS CONTROVERSY 109 

terious effect and inefficiency of hyoscin (scopola- 
min), but the stress of their contention must rest 
on their experiences, and they differ so widely from 
that of Gauss that on one side or other a large 
personal equation must be allowed. ,, 

Max Salzberger of Kulm (in Western Prussia) 
in his publication, " On Danger to Child from Sco- 
polamin-morphin Administered during Birth," says : 

" Hocheisen, as well as Steffen, mentions in- 
stances where muscular action was completely 
stopped. Of course their method of dosage is 
quite different from Gauss's in spite of their asser- 
tions to the contrary." 

Preller of Mannheim says : 5 

" On the strength of 100 cases observed by him, 
Hocheisen came to the conclusion that scopolamin 
should be condemned on account of its dangerous- 
ness. I believe such rigorous judgment to be un- 
justified." 

Wilhelm Tichauer of Breslau in " Scopolamin- 
Morphin in Obstetrical Practise " (published in 
191 1 ), in writing of Hocheisen's experiments, 
says: 

" It is clear that the procedure varied consider- 
ably, and then in the most important points, from 
that described by Gauss. Under such conditions 
5 Munch. Med. Wochenschr., No. 4, 1907. 



no THE TRUTH ABOUT TWILIGHT SLEEP 

it is not to be wondered at that Hocheisen obtained 
quite different results. On the strength of his ex- 
periments Hocheisen considered it his duty to warn 
doctors against the use of the method, especially 
in private practise. It must be borne in mind that 
in the case of such a difficult procedure as that of 
producing Twilight Sleep, initial failures were natu- 
ral and at first unavoidable, and they must be all 
the greater when the medical man in question does 
not utilize the experiences of his predecessors and 
does not accurately follow the procedure laid down 
by them — a procedure based on their experience 
— but goes his own way. Under the circumstances 
Gauss's Dammerschlaf can hardly be debited with 
Hocheisen's failures." 

Now for the von Bardeleben report : 

"At first I was extremely in favor of the 
method," he says, " because of the success of our 
early experiments. 

" One patient after bearing in Twilight Sleep 
declared quite jauntily, * Having babies at your 
clinic is so painless, I should not mind looking you 
up again next year.' 

" The subsequent results of our experiments de- 
creased my enthusiasm. 

" It became an almost constant occurrence, in our 






HOCHEISEN-GAUSS CONTROVERSY III 

confinement ward, for a woman to remain for two 
or three days in labor without definite results. 

" Recently the midwife asked me whether these 
injections might not be stopped so that the torture 
resulting therefrom to the staff, who had to watch 
the patient for two or three days, could be put to 
an end. 

" The labor pains after the scopolamin injections 
occur less frequently and after longer intervals. 

" The effect on each individual differs in an in- 
calculable manner. The most serious influence is 
on the abdominal action." 

As the following " scopolamin death " of von 
Bardeleben has been given such notoriety, I shall 
give a full account of it in his words so you may 
draw your own conclusions as to how far scopola- 
min was to blame. 

" Four hours after an injection of .0003 g. sco- 
polamin spontaneous delivery took place without 
any disturbance. The Dammerschlaf seemed espe- 
cially successful, the mother perceiving nothing of 
the birth, but afterward she complained of a dull 
feeling in the head, her pupils were enlarged, the 
heartbeats increased, and breathing was shallow. 
About two hours after birth there was a slight hem- 
orrhage which soon ceased. Two hours later there 
was renewed hemorrhage on the removal of the 



ii2 THE TRUTH ABOUT TWILIGHT SLEEP 

placenta ; this hemorrhage was stopped after rinsing 
of the uterus; up to now the patient had lost about 
half a pint of blood. After a further half hour 
hemorrhage began again, the patient losing a fourth 
of a pint of blood. Pulse was unchanged. After 
another half hour pulse became weaker and the pa- 
tient collapsed suddenly; the breathing became 
superficial and weak and she lost consciousness. I 
applied at once an injection of two pints of salt 
water and gave injections of camphor and caffein 
without avail. Massage of the heart was continued 
for one hour but I could not reinstate spontaneous 
respiration. There was no suffocation, no gasping, 
the breath became slower and slower, the pulse ever 
more rapid and so the woman perished. It seemed 
to me like an experiment on an animal ! 

" Scopolamin acts upon the breathing center and 
upon the heart; nevertheless, I believe it would be 
too hasty a conclusion to say this was only the 
effect of scopolamin or a direct case of poisoning. 6 
The loss of blood probably played its part in the 
death. But I feel justified in saying that the pa- 
tient did not survive the hemorrhages because she 

6 Kionka, of Jena, in Therap. d. Gegenw. (1908) says, "I 
reject the statement that scopolamin is a cardiac poison and 
injures the muscles of the heart. The breathing is affected 
and the heart action stopped only after quite enormous doses 
as compared to those which attain a usual narcotic effect." 



HOCHEISEN-GAUSS CONTROVERSY 113 

was at the same time under the injurious effect of 
scopolamin. The postmortem bore this out; a 
greater quantity of blood was found in the lungs 
and very little in other organs ; this can be attributed 
to asphyxia, but it may also occur in anemia. " 

I want to give Gauss's reply almost literally from 
my translation, for this answer made eight years 
ago to these, some of his most distinguished and 
violent opponents (Bumm, Hocheisen, and von 
Bardeleben), still stands to-day as one of the most 
trenchant and all-embracing replies he has ever 
made to his critics. 

Gauss begins by saying : " I want to ask Herr 
Hocheisen what preparation has been used." 
Hocheisen : " Merck's." 
G. : "What initial dose was given?" 
H. : ".0003 to .0005 g. scopolamin." 
G. : " Together with .01 g. morphin? " 
H. : "According to the effect. If the effect 
was quick no morphin was given; if no effect oc- 
curred, I gave .01 g." 

G. : " By what did you judge the effect? " 
H. : "I judged the time when I found the sen- 
sation of pain was no longer perceived. The 
second injection was without morphin or again .01 
g. morphin." 



114 THE TRUTH ABOUT TWILIGHT SLEEP 

Gauss : " As the drug cannot have this curious 
difference in its results and as furthermore the drug 
used appears to be the same, the cause of the vary- 
ing result can only be ascribed to difference in tech- 
nic. The reply to my last question confirms this, 
as I had expected. Your judgment of the effect 
is absolutely different from the method indicated 
by me. The second injection is not to be given 
when it is ascertained that the recurring pain can 
no more be apperceived but when certain varying 
impressions of the senses are no more apperceived. 
I believe that this elementary difference in our tech- 
nic is the explanation for the whole series of fail- 
ures which, to my regret, Herr Hocheisen has 
reported. 

" I may perhaps once more give a brief sketch 
of my technic used to induce Twilight Sleep. I 
give a patient with labor pains occurring within 
from five to ten minutes .0003 g. to .00045 g. sco- 
polamin together with .01 g. morphin and then I 
wait about two hours; if there is still a clear ap- 
perception of sense impressions I give her a further 
but smaller injection of .00015 g. scopolamin with- 
out morphin; the test of apperception of sense im- 
pressions is made as follows : I examine a patient 
and then about one-half hour later I ask her, ' Have 
you been already examined to-day ? ' She says, 



HOCHEISEN-GAUSS CONTROVERSY 115 

1 Yes,' then I know that the sense impression, at 
the time of examination, was stored in her memory 
or apperceived. I give her now a second injection 
of before mentioned strength, .00015 g. scopolamin. 
Then I wait once more half an hour. As a rule 
after ten minutes perceptible changes in the clinical 
aspect occur. I ask her now, for example, ' How 
many injections have been made?' She says, 
' Two.' This shows that at the time of second in- 
jection she was still clearly conscious. If I show 
her a knife and ask her one-half hour later, while 
showing her the knife again, ' Has this instrument 
been shown you before? ' then she may say, ' No.' 
From this moment it is certain that she is in the 
Dammerschlaf. 

" If I have correctly understood Herr Hocheisen, 
he continues to administer scopolamin until the 
pain as such is no more apperceived. 7 This would 
be such a tremendous difference of technic that the 
whole secondary effects, which appear to be very 

7 Gauss had clearly stated that the patient's complaints about 
continued suffering could be no criterion by which to judge 
the effects of drugs, because even after the patient is in the 
state of Dammerschlaf she may still cry out loudly at each 
pain; this apparently perceived pain is not recalled at all after 
birth. If Hocheisen used the "apperceived pain" as a test, 
he then undoubtedly,, in many cases, must have continued in- 
jections upon a patient already completely in a state of Dam- 
merschlaf — the result would be serious overdosing. 



u6 THE TRUTH ABOUT TWILIGHT SLEEP 

regrettable ones, must be characterized as the conse- 
quence of relative overdosage. 

" I may now enter upon the series of reproaches 
made by Herr Hocheisen against my method. It is 
rather difficult to answer all his objections, as al- 
most the entire category of disagreeable accidents 
to women in labor and childbed which could happen 
have been mentioned by him. It is beyond my ken 
in what degree the observations were made object- 
ively and in what degree the proofs of his accusa- 
tions are irrefutable. With regard to his point, 
that occasionally considerable chloroform had to be 
used, as there were violent states of agitation, I can 
only say I have not made any observations of a like 
character. We suppress any cases of slight agita- 
tion by use of chlorethyl. If among Hocheisen's 
ioo cases there were only six of complete amnesia 
at birth, this may be only the consequence of in- 
correct or intermittent control of Dammerschlaf. 
Among nearly 1,000 births treated by me with 
scopolamin there were at least 70 per cent, of the 
births with more or less complete amnesia, so that 
the patient from the moment of effective injection 
did not remember anything about the birth. I have 
never observed such great subjective and objective 
disturbances as I have heard reported to-day. 

" I believe to have been misunderstood when I 



HOCHEISEN-GAUSS CONTROVERSY 117 

made statements about the seclusion of patients. 
Seclusion is only possible with patients who are de- 
livered in private wards; as at Berlin, we also have 
in our other wards several women in labor together ; 
to separate them entirely from each other is of 
course not possible, but we try to seclude them as 
much as we can. Our best results are obtained by 
absolute seclusion. 8 

"I begin now on the subjective side effects; it 
cannot be denied that vomiting, red face, vertigo, 
unrest, delirium, and twitchings make an ugly im- 
pression, but I cannot understand that this bad im- 
pression should have a decisive influence upon the 
use or disuse of a drug. If some of these effects 
occurred after scopolamin-morphin injections, they 
need not have been caused by the effect of drug. I 
believe, at least, that an equal number of such side 
effects may and do occur without scopolamin; 
vomiting, headache, perspiration, are symptoms 
which may occur at any birth. I do not deny that 
thirst, twitching of hands, and red face are the ef- 

8 Kr6nig in a 1908 publication says: "When 6 or 7 par- 
turient (childbearing) patients lie side by side in one ward 
it is obviously impossible to obtain an even fairly effective 
semi-consciousness. The number of cases in which we obtain 
loss of memory is far smaller in those deliveries which occur 
in the general ward than in the case of patients treated in 
the private wards where they lie in a separate room protected 
as far as possible from all impressions of sight and hearing." 



n8 THE TRUTH ABOUT TWILIGHT SLEEP 

fects of scopolamin. But I do not find in the least 
that I have ever had the impression of pronounced 
poisoning in my patients such as have been described 
by Herr Hocheisen. 

" I believe the constant presence of a practitioner 
to be necessary on account of the calculation of 
doses. 

" Among the objective side effects there has been 
mentioned an influence upon the labor; if I have 
observed an improvement of the labor in 30 cases it 
means that the labor has been stimulated consider- 
ably toward the end of the birth. In 21 cases of 
Hocheisen's the labor became so weak that some- 
times it stopped altogether. Since making use of 
considerably smaller doses of scopolamin than those 
used formerly and desisting almost entirely from 
the use of morphin, I have not observed any weak- 
ness of the labor. In those few cases where labor 
is diminished so that there is a risk to the process 
of birth I have naturally stopped the scopolamin in- 
jection. 

" According to Hocheisen, abdominal action was 
diminished in 24 cases, 4 of which required forceps. 
It is, I believe, an accident that during the last three 
months of my statistics published, I had a rela- 
tively high frequence of forceps, whilst during the 
following six months I had altogether only 10 for- 



HOCHEISEN-GAUSS CONTROVERSY 119 

ceps cases without having altered the method. In 
any case we have at present no more forceps births 
in Freiburg than we had formerly, although we now 
give every patient that enters the delivery ward 
scopolamin injections. The frequence of operative 
interference is at present even smaller than form- 
erly. Compared with the time of Professor 
Hegar's directorate at Freiburg it is greater, because 
the life of the child is at present of greater impor- 
tance than was formerly the case. 9 With regard to 
the observation that it would be easy to use forceps 
in 25 per cent, of all scopolamin cases, I have noth- 
ing to reply, because if that were true then we 
would have to use forceps continually in Freiburg 
and such is not the case. 

" As to the duration of the birth, which has been 
here discussed in detail, I remember that during our 
first large dosage of morphin a duration of three 
and a half hours was usual in case of first child 
and an hour and a half in other cases was the rec- 
ord, so that the duration of births scarcely exceeded 
the time calculated by Herr Bumm to be the normal. 
If Professor Bumm seems to arrive at the low fig- 
ure of one and three-quarters hours as the length of 

9 Hegar always insisted on saving the mother irrespective 
of danger to child, and he was disinclined to use the forceps 
on account of possible injury to the mother. 



120 THE TRUTH ABOUT TWILIGHT SLEEP 

normal birth in his publication, this may be ex- 
plained by his calculating only uncomplicated head 
presentation, excluding narrow pelvis, placenta 
praevia, and other complications. All conditions 
have been included in my statistics. 

" The after-birth period in scopolamin-morphin 
has not only not been retarded, but the after-birth 
was never before expelled spontaneously within the 
first half hour until we began our use of scopolamin. 
Extreme debility or atony" (wanting in tone or 
vigor) " I have not witnessed more frequently 
among my cases than occur generally, not to men- 
tion that among my one thousand scopolamin 
mothers we have not had a single case of a mother 
bleeding to death. 

" We always await spontaneous course of after- 
birth. As to the disposition of the uterus to relax, 
I have not seen it more in scopolamin births than in 
births without. 

" With regard to child-bed I can make no com- 
parison with the figures of Hocheisen, as for a con- 
siderable time we have let all the patients get up 
within the first days after birth, thereby, one might 
think, a good contraction would be rendered impos- 
sible, but curiously enough the reproductive organs 
of patients upon the sixth or seventh day are con- 



HOCHEISEN-GAUSS CONTROVERSY 121 

tracted so much that the uterus is very often already 
in the small of the pelvis. 

"If Herr Hocheisen ascribes the heart attack of 
the patient with mitral stenosis 10 to scopolamin, I 
do not know that I care to follow him in his some- 
what phantastical conclusion. The alienists, who 
often give doses up to 4^ mg. per day, have never 
had such accidents, although these are quite in- 
credible doses. If mitral stenosis is found in a case 
of heart disease we need not search for other ex- 
planations, although I do not wish to deny that 
scopolamin injections in such a case would more 
easily have a serious consequence than in the case 
of a sound heart. 

" Twenty per cent, of Hocheisen's cases have 
shown decrease of pulse. If we have ever observed 
any change in pulse it has only been an accelera- 
tion. 

" It has been stated that we treat eclampsia with 
scopolamin; we treat such patients invariably by 
using forceps and give scopolamin besides, not with 
the intention of curing the condition, but solely in 
order to quiet patients and make them less sensi- 
tive to exterior impressions. 

" Herr Hocheisen mentions disturbances of res- 

10 Contraction of the mitral valve of the heart. 



122 THE TRUTH ABOUT TWILIGHT SLEEP 

piration and heart as being counter-indications. 
Curiously enough I must say that we intentionally 
give scopolamin precisely when patients are labor- 
ing under any disturbance of the breathing organ- 
ism as, for instance, in cases of pneumonia and 
bronchitis. We have thereby made the discovery 
that patients can then more easily stand difficult 
operations and long narcosis, whereas formerly we 
would not have operated on such cases, consider- 
ing complications of the lungs. 

" The fact that we use scopolamin in case of nar- 
row pelvis shows that we do not find that proper 
doses of scopolamin protract the birth process. 

" With regard to the child ; Hocheisen has ob- 
served 1 8 per cent, (as compared to 23 per cent, 
observed by me) of apneic children; I have to say 
that this 23 per cent, mentioned in my former sta- 
tistics has lately been reduced to 7 per cent, in 120 
cases. This shows that since the dose has been 
guided solely by the memory test the effect upon the 
child has been reduced. Among 120 born last week 
at the clinic, 103 were lively, 7 asphyxiated — that 
is to say no were born without intoxication; 7 were 
partly oligopneic, partly apneic. I consider these 
two conditions to be a difference in degree of in- 
toxication — apneic being the greater degree. 
Three children were born dead. 



HOCHEISEN-GAUSS CONTROVERSY 123 

" I think it is a mistake to consider asphyxia as 
an aspect of scopolamin poisoning. If the child is 
poisoned by scopolamin it shows unmistakable symp- 
toms, viz. : a feeble movement of eyelids and a crip- 
pling of the reflexes (involuntary movements, such 
as winking the eyelids). In my statistics only 
that per cent, of children born without intoxica- 
tion was stated as asphyxiated. I must decline 
to admit asphyxia to be always a consequence 
of birth protracted by scopolamin, because if all 
births were protracted in our clinic, in the manner 
they seem to have been protracted in the cases here 
stated, we would be unable to accommodate all the 
patients, at the same time seeing that we give them 
all scopolamin. I have not seen the proof that 
asphyxia caused by aspiration could be a result of 
scopolamin, as both aspiration and asphyxia occur 
also without scopolamin. The number of children 
that are still-born is not only as small as previously 
at our clinic, but it has been reduced. 

" I cannot agree with the fear that the apneic chil- 
dren would perish if they were not artificially 
roused. I have waited up to twenty minutes when 
I found that they breathed again in normal rhythm. 
If Hocheisen and von Bardeleben had cases where 
the children were oligopneic up to three-quarters of 
an hour and if then sometimes assistance was neces- 



i2 4 THE TRUTH ABOUT TWILIGHT SLEEP 

sary without which the children would have died, 
this is only, to me, a confirmation of my supposition 
that their technic and dosage were very different 
from mine, because among the 1,000 children in my 
statistics some would then have undoubtedly died, 
because I gave no assistance to them. I may once 
more point out, that in order to call a scopolamin 
Dammerschlaf irreproachable, a child should be born 
lively. A birth resulting in protraction and an ap- 
neic child can always be considered as an indication 
of miscalculated scopolamin doses." 

Geheimrath Bumm, replying to Gauss, said: 
" We believe that in questions of mitigating pain 
we should ask patients whether they still feel any 
pain. Herr Gauss enlightens us now by explaining 
that we should, on the contrary, only ask if she ' ap- 
perceives ' a knife, for instance, and then calculate 
our doses accordingly. I cannot believe that the 
vast difference which has been shown to exist be- 
tween our observations and those of Gauss are 
caused by the difference in method or technic, but 
by the difference of the manner of observation. It 
is possible to look at a thing soberly and to look at 
it optimistically ; we made our observations soberly." 

Hocheisen, then rising, defends his quantity of 
dosage, pointing out that in 44 cases Gauss's small- 



HOCHEISEN-GAUSS CONTROVERSY 125 

est initial dose had not been exceeded ; he adds : " I 
do not care to go into details about the technic of 
Gauss's Dammerschlaf, as I consider it too hair- 
splitting and complicated. Our technic was to con- 
sider the complaints of the mother as an indication 
of the scopolamin effect. If the patient still com- 
plained of pain, the pain was evidently not dimin- 
ished and she was suffering; perhaps she does not 
1 realize ' the pain, but this is not what we call a 
1 painless birth/ either from the point of view of the 
practitioner or the lay public." 

In conclusion, he says with unconscious prophetic 
emphasis : 

" The future will show who is right. If scopo- 
lamin remains, Herr Gauss will be right; if it dis- 
appears, I shall be right." 



VII 

Gauss's Published Reply to Hocheisen 

THE Bumm-Hocheisen denunciation of the 
Dammerschlaf was too serious a matter to be 
ignored. As a result Gauss immediately made a 
public reply. 1 

After only ioo cases, Hocheisen felt justified in 
condemning the method. In Gauss's reply he gives 
the results of his own first 1,000 cases. 

" It is important now to discuss this matter on 
principle/' writes Gauss, " as all the late medical 
literature contains reports on scopolamin-births 
which, in spite of apparently dealing with the same 
object, show great difference in method. 

"Of all the publications on the subject only that 
of Preller, of the Mannheim Asylum for Women in 
Childbed, gives a description of scopolamin-morphin 
technic similar to our own. 

" Hocheisen's technic differs so entirely from that 

1 " Report on My First 1,000 Births in Scopolamin-Morphin 
Dammerschlaf," by C. J. Gauss. Miinch. Med. Wochenschr., 
pages 157-161, 1907. 

126 



GAUSS'S REPLY TO HOCHEISEN 127 

of the Freiburg method, it is impossible to draw a 
parallel. 

" The important question is not what is given, but 
how it is given." 

Hocheisen rather unfairly used the reports on 
the use of scopolamin for sedative and narcotic pur- 
poses to deduce opinions as to the harmfulness and 
incalculability of the drug in obstetrics. As long as 
he was doing this it seems remarkable, as Gauss 
points out, that Hocheisen failed to refer to the 
most important paper on scopolamin published by 
any alienist — that of Bumke, of the Freiburg In- 
sane Clinic (Director Geheimrath Hoche). 

In this clinic they have made many thousands of 
scopolamin injections. At an average, sixteen pa- 
tients daily receive single doses of .001 or .0005 g. 
scopolamin, the maximum dose rarely exceeding 
.001 g. In the case of cataleptic women, maximum 
total dose of 4^2 mg. are repeatedly reached in 
twenty-four hours. 

Such symptoms as are cited by Hocheisen have 
never been observed in Hoche's clinic, and it is there 
denied that any serious disturbance of the general 
state of health occurs as a result of the injections. 

According to Bumke, breathing, in scopolamin 
sleep, is somewhat deeper than in ordinary sleep, but 
it is never irregular or difficult. Bumke cites Edlef- 



128 THE TRUTH ABOUT TWILIGHT SLEEP 

sen and Illing, who have employed scopolamin to ad- 
vantage in asthma ; he further cites Korn, who used 
.01 g. scopolamin on a patient with heart disease 
(in spite of emphysema 2 ) without causing the 
slightest symptom of suffocation. 

Although scopolamin is excreted through the kid- 
neys, Gauss says no injury to the functions of these 
organs has ever been proved. 

" My first investigations upon fifty cases showed 
no effect of scopolamin upon the kidneys and my 
last investigations in one hundred cases attain the 
same result. 3 

" Further to support his warnings against scopo- 
lamin Dammerschlaf, Hocheisen cites the records of 
scopolamin-morphin narcosis in surgery. Many be- 
sides Hocheisen bring up this comparison time and 
time again, and so mislead the general opinion about 
the effect of scopolamin and thereby sustain a fear 
of the drug. 

" One should not lose sight of the vast difference 
between the surgical dose of .0036 g. scopolamin + 

2 A swelling produced by air, as dropsy is caused by liquid. 

3 Statistics of 100 cases — 

At Birth When Leaving Clinic 

80 — No albumen No albumen 

12 — Albumen No albumen 

3 — Albumen Albumen 

1— No Albumen Albumen 



GAUSS'S REPLY TO HOCHEISEN 129 

.03 g. morphin administered in three hours and the 
administration of only a small fraction of this 
quantity, spread over a manifold longer period, in 
Twilight Sleep. 

" As far as I can discover, all death cases associ- 
ated in literature with scopolamin-morphin have oc- 
curred during scopolamin-morphin surgical nar- 
cosis." 

As Bumke has observed, in most of these cases 
there is no complete record of all the details which 
alone could furnish proof that scopolamin was the 
cause of death. There is also a singular absence of 
statements about the age and condition of the scopo- 
lamin employed. 

" As a matter of fact," says Gauss, " it is not at 
all surprising that Roith's dose of .0036 g. scopo- 
lamin to .03 g. morphin should have proved fatal — 
it is rather a matter for wonder that anybody should 
have expected the contrary." 

Then, too, we must take into consideration those 
certain rare instances of a patient's intolerance or 
idiosyncrasy to the drug, but such cases should not 
discredit the drug in the face of the many thousand 
favorable cases. As Tichauer of Breslau says: 
" It would be absolutely unjustifiable to deprive all 
women of the benefit of scopolamin because of the 
rare cases of individual idiosyncrasy." 



130 THE TRUTH ABOUT TWILIGHT SLEEP 

Bumke says : " It would be of great advantage if 
the harmlessness as well as the positive good results 
of scopolamin could be more widely known. ,, 

To quote Gauss again: "After Hocheisen had 
claimed to have followed my method, let us look at 
the actual facts : He says : ' I do not consider 
at all Gauss's statements about diminished faculty 
to remember, summary memory or participation of 
single sense organs, as the scopolamin sleep of our 
patients showed such different symptoms that, from 
our cases at least, I could not establish a gage for 
such fine physiological-psychical observations.' 
These words contain a clear renunciation of my main 
guide in scopolamin-morphin Dammerschlaf. I re- 
peat my words : ' Without a continuous, tactful 
test of the state of consciousness it is impossible to 
maintain an effective continuity of artificial Dam- 
merschlaf.' Hocheisen exposed himself to failure 
by his disregard of these instructions. He admitted 
quite frankly that he continued to administer scopo- 
lamin until the pain of labor was no longer apper- 
ceived ; naturally then all the serious side effects oc- 
curring in his cases were certainly the consequences 
of relative overdosage. 

" It is, furthermore, really surprising that Bumm's 
clinic had not more disagreeable incidents, consid- 
ering the fact that the ioo cases were not treated by 



GAUSS'S REPLY TO HOCHEISEN 131 

one physician but two, for it is natural with so diffi- 
cult a technic as that required to induce and main- 
tain a Dammerschlaf, that failures must occur until 
a positive experience with the method has been ac- 
quired by the physician." 

GAUSS'S EXPERIMENTS WITH THE HOCHEISEN 
SOLUTION 

In order further to discover the cause of Hoch- 
eisen's failures, Gauss obtained from Hocheisen 
some of the Berlin Charite solution. In unpacking 
it, he noticed a fine sediment which, upon shaking 
the vial, caused the whole liquid to be clouded. To 
conclude that such a condition was merely caused by 
transportation, Gauss considered " far-fetched." 
He then proceeded to experiment on ten patients 
(poor patients!) with the Hocheisen solution. The 
narcotic effect was so strong and rapid that in three 
out of seven cases Dammerschlaf occurred within 
one and a half hours. One sleep was attended by 
deep coma with great influence upon abdominal and 
labor action ; three times heavy atonic hemorrhages ; 
one deeply apneic child ; four times great excitement ; 
one case of vertigo; one lasting case of vomiting. 4 

* Gauss observes that Hocheisen also evidently did not use 
the test of scopolamin advocated by Otmar G. Kessel of Jena 
Pharmacological Institute (at that time used in Freiburg be- 
fore the Straub investigations were made, on which we will 



132 THE TRUTH ABOUT TWILIGHT SLEEP 

" The cloudiness of this solution," says Gauss, 
" probably indicated fermentation of apatropin." 

A second unclouded solution sent Gauss by Hoch- 
eisen produced almost equally bad results ; one deeply 
apneic child ; one case had to be terminated by for- 
ceps because of cessation of labor; three cases of 
atonic hemorrhages. As Hocheisen apparently did 
not note form, age, origin, or manner of prepara- 
tion, or storing of drug, Gauss feels justified in as- 
cribing, still further, the bad side effects to Hoch- 
eisen's use of a drug in spoiled condition. 

Gauss proceeds : " As Hocheisen states that the 
' scopolamin Dammerschlaf is not in accordance with 
the duties of a conscientious doctor/ I have felt it 
necessary to go into a somewhat lengthy reply to his 
criticisms before reporting on my 1,000 births. I 
shall first consider the disadvantages which, accord- 
ing to Hocheisen, must be ascribed to scopolamin." 

MORTALITY OF MOTHERS 

" Among my first 500 cases there was not a single 
death of a mother. Among the last 500 there was 
one death, but it could not be ascribed to scopolamin. 

write later), of a drop of thin solution of calcium perman- 
ganate. If the solution contains apatropin this test is so 
sensitive that in a solution of one part apatropin in 20,000 
parts of the 40 per cent, watery scopolamin solution, the solu- 
tion shows a reaction. 



GAUSS'S REPLY TO HOCHEISEN 133 

It was a case of colporrhexis on account of very 
narrow pelvis; even laparotomy" (cutting into the 
abdomen), " immediately resorted to, could not save 
the patient from bleeding to death. 

" Among these last 500 there were 23 women 
with pronounced heart disease (cardiac lesions). 

"If scopolamin does really endanger the heart, as 
Hocheisen claims, it seems very curious that we did 
not have a single attack of heart trouble. 

" Since 1905, in addition to my own close control 
of the patient's heart, Professor Clemens, and later 
Dr. Link, have examined every patient before child- 
birth to ascertain the condition of both heart and 
lungs. 

" Hocheisen points out ' the danger of hemor- 
rhage from the use of scopolamin.' I have meas- 
ured the blood loss in a series of 363 patients during 
the placental period, so I am in a position to reply 
to this statement with figures. 

337 times (92.8 per cent.) lost up to 500 g.= average of 

190.4 g. 
23 times ( 6.3 per cent.) hemorrhage from 599 to 1,000 

g.= average of 645.5 g- 
3 times ( 0.9 per cent.) hemorrhage endangering life, 

of from 1,000-1,500 g.= 

1,255 g- ^ 
510 times = 51 per cent, the after birth in 1,000 cases 

was spontaneous. 



134 THE TRUTH ABOUT TWILIGHT SLEEP 

481 times = 48.1 per cent, by slight pressure (Crede). 

4 times = 0.4 per cent, by manual loosening. 

5 times = 0.5 per cent, by manual loosening with 

Caesarian section. 5 

" By comparing the above figures with others' 
statistics the results are bound to be very much in 
favor of scopolamin." 

THE USE OF FORCEPS 

" As a test of Hocheisen's statements as to the 
excessive prolongation of birth, let us glance at the 
forceps statistics of my 1,000 births. Among the 
first 500 there were 49 forceps = 9.68 per cent. 
Among the last 500 there were 25 forceps, making a 
total in the 1,000 cases of 7.32 per cent. 

" Even such an illustrious obstetrician as Bokel- 
manns confesses to a necessity to apply forceps in 
40 per cent, out of 335 private cases reported on in 
his paper read at Berlin. This report was published 
without causing criticism or comment from his 
fellow physicians." 

Among 163 further private Dammerschlaf cases 
of Gauss's, conducted outside of the clinic and not 
included in his 1,000 births, he did not use the for- 
ceps in a single instance. As Gauss says : " We 

5 An abdominal incision for extracting the child from the 
uterus. This operation was first performed by a Dublin mid- 
wife. 



GAUSS'S REPLY TO HOCHEISEN 135 

are in the agreeable position that we may conduct a 
birth independent of the complaints of the women 
in labor and above the reproaches of the impatient 
and anxious relatives, as we know that the patient 
in complete Dammerschlaf has absolute amnesia " 
(impairment of memory of pain) ; '" considerations,' 
to quote Herr Hocheisen, * for the surrounding lay- 
public which is expecting a painless birth in physi- 
ological sleep,' which so concerned him do not con- 
cern us or influence us in the slightest from desisting 
from Twilight Sleep. ,, 

Wilhelm Tichauer, commenting in 191 1 on the 
Gauss-Hocheisen controversy, says, in regard to 
Hocheisen's claim that " a lay-public which is pres- 
ent at a Dammerschlaf birth receives a very bad im- 
pression from the side effects " — " surely," says 
Tichauer, " such considerations should not induce a 
doctor to deprive a woman in labor of the benefit of 
lessened pain. It seems much more simple to keep 
the lay-public away from such patients or, if such 
should not be feasible, to simply warn them before- 
hand of what is to be expected." 

THE CHILD 

As to the new-born, as Gauss clearly pointed out 
in his first publication, if the memory is carefully 
tested, overdosing of the mother is avoided and the 



136 THE TRUTH ABOUT TWILIGHT SLEEP 

consequent bad effects on the child. In the sta- 
tistics of his 1,000 births, Gauss found the per cent, 
of oligopneic children greatly lessened by a reforma- 
tion of the early doses of morphin and an improve- 
ment in technic. There were in the last 50 cases 
only 5 oligopneic children," and these were births in 
which the desired effect had to be attained in the 
short period of from two to six hours on account 
of the late arrival of the mothers at the Frauen- 
klinik, which necessitated an injection of .0012 g. 
scopolamin, and in one case .0015 g. scopolamin. 
In the majority of cases where there was ample time 
in which to begin the Dammerschlaf, there were no 
bad effects on the child. In the later 500 births the 
statistics were as follows: Lively 78.6 per cent., 
oligopneic 12.7 per cent., asphyxiated 6.3 per cent. 

" In 117 not especially selected cases of more re- 
cent date," reports Gauss, " there were only 6 per 
cent, oligopneic children. 

" Since the adoption of scopolamin at the 
Frauenklinik, the number of children dying from in- 
juries at birth has been reduced by 3 per cent. 

"Among Lehmann's 70 scopolamin births there 
was no death of a child. Among Preller's 220 
cases only one child died and that, he says, could in 
no way be ascribed to the effect of scopolamin." 

As for Hocheisen's concluding remarks in his 



GAUSS'S REPLY TO HOCHEISEN 137 

chapter on the child, viz. : " It remains to be seen 
whether it is unimportant to the mental and physical 
development of the tender organisms of the child 
that such a dangerous poison should be transmitted 
to it from the mother, when it is in the uterus," 
Hoche 6 replied, in his discussion at the Freiburg 
Society of Doctors, that such a conclusion is " ab- 
struse," and in the Munich Medical Weekly of 1907 
he furthermore adds : " This supposition of Hoch- 
eisen's belongs to the realm of comic fable." 

THE ONLY GUARANTEE OF SUCCESSFUL DAMMER- 
SCHLAF 

To attain the successful Dammerschlaf achieved 
at the Freiburg Frauenklinik, Gauss reiterates that 
only the most exact precautionary measures can 
guarantee success, and every individual woman in 
labor necessitates such extreme and intensive obser- 
vation of her individual condition of consciousness 
that it is difficult for one doctor to watch a number 
of patients at the same time and in the same room 
without having to fear overdosage. 

" The extent to which the method can be adopted 
in clinics and general practise depends entirely upon 
whether the respective doctor can and will take the 
trouble to follow out instructions closely. As long 

6 A nerve specialist of distinction. 



138 THE TRUTH ABOUT TWILIGHT SLEEP 

as these instructions are disregarded, we absolutely 
decline responsibility for injuries by scopolamin. 

" The security of Twilight Sleep and its particular 
effect are based solely upon the test of memory. 
He who believes he can use scopolamin without this 
continuous test is making a new method of his own, 
but it is no Dammerschlaf." 

The reply which Hocheisen made to this publica- 
tion of Gauss's holds absolutely no material and is 
not worth reproducing. I shall, however, give you 
his final words, as they at least show spirit and a cer- 
tain sort of picturesque stubbornness: 

" If I am right, scopolamin, together with the 
Gauss cleverly coined word ' Dammerschlaf,' will 
disappear from the scene after a time, just as many 
other loudly praised methods have done. If he is 
right, within a few years all women will share pain- 
less birth without risk and I shall then have to ad- 
mit having been wrong. For the present, however, 
I take the liberty to continue to warn all practi- 
tioners — the optimistic reports from Freiburg not- 
withstanding." 

EARLY RISING AFTER CHILDBIRTH 

In a short article published in 1907 following the 
report on his first 1,000 births under scopolamin- 
morphin, Gauss said he had adopted the method 



GAUSS'S REPLY TO HOCHEISEN 139 

recommended by Kustner with regard to the early 
rising after childbirth. " Anemia, debility, heart 
disease, varicose veins, existing or suspected infec- 
tion," says Gauss, " are strong indications to make 
the patient get up as soon as possible. Healthy 
mothers are permitted to get up when they choose. 7 
The state of health of the early risers is decidedly 
better than that of patients getting up later. The 
capacity for nursing shown by the patients who have 
risen early is also far greater than that of patients 
getting up later, a fact which presents new aspects 
for increasing the milk secretion. The involution of 
the abdominal layers of skin, in the case of early ris- 
ing mothers, was good when leaving the clinic as 
well as at a later examination in from six weeks to 
one year. Those whom I made perform gymnastic 
exercises showed more firm and rigid abdominal 
muscles than the others. The involution of the 
vagina showed similar favorable results. Compar- 
ative observation of the pulse showed no injury to 
the heart action. The sooner the patient gets up the 
more rarely fever is observed." 

7 At present it is the custom at the Frauenklinik to encour- 
age all mothers to get up the first day. In the case of any 
tendency to hemorrhage, the mother is made to get up almost 
immediately after delivery; this is to prevent the formation 
of blood clots and because of the benefit to the circulation 
generally. 



i 4 o THE TRUTH ABOUT TWILIGHT SLEEP 

BED EXERCISES 

These gymnastic exercises referred to by Gauss, 
I am able to describe from personal observation of 
mothers performing them. The first exercise con- 
sists of lifting the body entirely without assistance 
of hands, placing all weight of reclining body on 
the shoulders, elbows and heels, making an upper 
curve of body at waist to a degree that enables the 
nurse to place her arm between bed and middle back 
of patient; the nurse then assists with arm to fur- 
ther elevate the center of body to a still higher 
curve. 

The second exercise : The patient, lying flat with- 
out pillows, lifts one leg up perpendicularly, then 
swings it around in rotary motion; this exercise is 
then repeated with the other leg. 

The third : The body still lying flat, both legs are 
then flung upwards towards the head as if to go over 
head, and when they have reached their limit the pa- 
tient then grabs herself with both hands placed un- 
der the knees and pulls the legs upward as much fur- 
ther as she can get them. 

A fourth exercise I saw performed by an Ameri- 
can mother a few weeks ago, two days after child- 
birth. This mother had not been able to sit in an 
upright position for four years because of a stiff hip 



GAUSS'S REPLY TO HOCHEISEN 141 

and leg caused by blood poisoning at her last child- 
birth, in America, from injuries by forceps. 

During this American's first conversation with 
Dr. Kronig on her arrival at the Frauenklinik, she 
asked: "Won't scopolamin cure my leg?" 
" Oh ! you Americans ! " exclaimed Dr. Kronig, 
flinging up his hands in despair. " You expect 
scopolamin to perform the miracles of Lourdes." 

Dammerschlaf was induced at 7.30 at night after 
this mother had only experienced a slight backache ; 
the child was born at 1.30 a.m., and the mother 
awoke at nine o'clock the following morning not 
realizing that the birth had taken place. No for- 
ceps had been used, the birth had been perfectly 
normal and the child lively. The mother had no 
after pains, and no weakness or soreness. 

While I was present the second day after the 
baby was born, this patient suddenly discovered, 
while performing some exercises, that she had re- 
covered the use of her four years' disabled leg. 
Her joy was overwhelming. This discovery was 
also made in the presence of an American doctor 
who had come all the way from California to investi- 
gate the Gauss Dammerschlaf. 

The exercises, in which the discovery was made, 
were those of the leg revolution and another exer- 
cise, which I had not before seen ; the mother sat up 



i 4 2 THE TRUTH ABOUT TWILIGHT SLEEP 

erectly in bed (a thing she had not been able to do 
for four years because of rigidity of hip) and slowly 
let herself back without assistance of hands to the 
flat reclining position. 

The California doctor was amazed at the ease 
with which this was done, declaring that this ease 
proved the abdominal muscles to be absolutely re- 
stored to normal strength after the incredibly short 
length of time of fifty-eight hours after childbirth. 

The head nurse, summoned to hear the joyful 
news of the mother's recovery of the use of her limb, 
acknowledged that she had endeavored to stretch 
the muscles of hip during the Dammerschlaf, " but," 
said she, pointing to the wonderful new infant in the 
bassinet, " you have him to thank for your cure." 

The California physician then said : " The en- 
tire relaxation of the whole muscular system in 
childbirth has induced the recovery of the use of 
your leg muscles; the perfectly normal birth of a 
child produces a most wonderful physiological meta- 
morphosis in women — a woman is re-made, and her 
entire health reconstructed and made perfect. All 
births should have this effect, but with the lack of 
proper care of mothers before birth, the impatience 
of physicians at birth, and the unnecessary use of 
forceps, this benefit to mothers is unfortunately not 
the rule nowadays but the exception." 



VIII 

Dr. Preller's Experience With the Dam- 
merschlaf 1 

AFTER Hocheisen's report, it is really refresh- 
ing to read Preller's account of his experi- 
ments, which, as Gauss says, is the only one of this 
period which shows a close observance of the 
Freiburg rules. 

As the Hocheisen-Gauss controversy was still the 
absorbing medical topic of the day in Germany, we 
find Preller constantly referring to it throughout his 
report, with much criticism of Hocheisen. 

Altogether out of a total 1,000 births from Oc- 
tober 1906 to October 1907 at the Mannheim Klinik, 
'220 were treated with scopolamin-morphin. 

The first five hundred of these cases were treated 
by Preller's predecessor, Dr. Eckert. 

Preller says : " Eckert's small success necessi- 
tated great changes in the method followed by him. 
He used scopolamin and morphin in one solution in- 

1 " About the use of Scopolamin-Morphin in Obstetrics," 
by Preller, Assistant at the Mannheim Klinik, Munch. Med. 
Woch., No. 4, 1907. 

143 



144 THE TRUTH ABOUT TWILIGHT SLEEP 

stead of separate solutions, as recommended by 
Gauss. 

" The effect of Eckert's doses 2 was considerable 
scopolamin intoxication; the patients suffered enor- 
mously from heat, restlessness, reddened faces, 
hallucinations and delirium. 

" Like Gauss I have used drugs in separate solu- 
tions of .03 per cent, scopolamin and 1 per cent, 
morphin. Only by systematically following Gauss's 
instructions can a correct Dammerschlaf be ob- 
tained." 

Preller's extreme clearness of statement as to 
exact amount of scopolamin and morphin adminis- 
tered by him, makes his paper of great value. It is 
interesting to note that he continued to use morphin 
in the second and sometimes in the third and fourth 
injections — unlike Gauss — yet he apparently had 
no bad effects therefrom. 

The first injection of .000375-00045 g. scopo- 
lamin + .01 g. morphin was given when the pains 
occurred at intervals of from 5-7 minutes. 

I think Preller has given us the keynote of the 

secret of success in Dammerschlaf in the following 

words : 

2 Eckert's dose was .009 g. scopolamin + .01 g. or .02 g. 
morphin in 20 g. of water; one full needle at first injection 
and one-half or again a full needle given at one to several 
hours later. 



DR. PRELLER'S EXPERIENCE 145 

" The results depend entirely on the experience of 
the physician in cautiously giving the. first dose and 
in subsequent carefully calculated doses according 
to the condition of patient. " 

He continues : " I have had cases where .000375 
g. scopolamin + «oi g. morphin produced a Dam- 
merschlaf lasting two hours without waking even 
during vigorous labor, while in other cases .0006 g. 
scopolamin + .01 g. morphin had but little ef- 
fect. 

"If first injection does not attain the desired ef- 
fect, a second injection of exactly calculated dose, 
varying between .0001 5-. 0003 g. scopolamin + .003 
-.004 g. morphin, is then given. 

" By this method a too rapid or immediate effect 
of the drug is avoided and a progressive calming of 
the patient is attained without any danger. 

" Within about a half hour after the second injec- 
tion the patient generally shows symptoms of being 
in the Dammerschlaf. In my third and fourth in- 
jections I frequently find an addition of .004-. 006 
g. morphin necessary. 

" In rare cases of especially robust women (who 
would doubtlessly have shown an equally strong re- 
sistance to other narcotics) and in cases of vehe- 
ment labor with narrow pelvis, I have found it 
necessary to give a first dose of .0006 g. scopolamin 



146 THE TRUTH ABOUT TWILIGHT SLEEP 

+ .01 g. morphin, following it with a second injec- 
tion of .0002 g. scopolamin with morphin again. 

" The total quantities used by us during entire 
narcoses never exceeded .0015 g. scopolamin or .02 
g. morphin, even in our longest cases, lasting six- 
teen hours." 

In Preller's 120 cases he attained Dammerschlaf 
in 70 per cent. 

He says : " I use the term ' successful Dammer- 
schlaf ' in a somewhat wider sense than others 
might, or even Gauss himself would, for my princi- 
pal aim is to attain a quiet sleep during the intervals 
of labor, the patient waking during pains and be- 
coming momentarily conscious of the suffering. 
This I consider a sufficient effect, for the patient's 
suffering leaves little or no trace in the memory 
afterwards." 

Preller was up to this time the only doctor who 
was content to produce this less than semi-narcosis ; 
the others forced the patient into a state of positive 
narcosis in which there was a deadening of the fac- 
ulties and a paralysis of the muscular action, or else, 
by a too swift development of Twilight Sleep 
through miscalculation of the proper time for the 
second and third injections, produced a condition of 
poisoning in the patient which evidenced itself in 
violent side effects. 



DR. PRELLER'S EXPERIENCE 147 

" It is so easy," says Preller, " to go a step fur- 
ther and induce a deep sleep during which the 
strongest pains are no longer consciously perceived 
and in which the patient only groans slightly when 
labor is at its climax. If this deep sleep passes 
without resultant poisoning, well and good, but it is 
certainly taking very great chances and is entirely 
unnecessary." 

Preller does not agree at all with either Hoch- 
eisen or Steffen as to the very bad impression made 
upon any of the lay-public who may be present at a 
Twilight Sleep birth. 

Dr. R. C. Buist, of Dundee, gives a delightful ac- 
count of what he calls Steffen's " lurid description 
of the patient in Dammerschlaf," which may be 
summarized " as a scene in which the patient with 
congested face talks at large or insists on getting 
out of bed, while the bystanders, and especially the 
nurses, miss the usual piousness of the lying-in 
room, in somber anxiety as to whether the mother 
will live or the child, whose heart the doctor con- 
stantly auscultates, will breathe; and in which on 
the birth of the child the mother's joy is replaced by 
a drunken disbelief in her surroundings ! " This 
description, says Buist, " does not at all correspond 
with the impression I have received from the cases I 
have seen." 



148 THE TRUTH ABOUT TWILIGHT SLEEP 

In Preller's first-class ward he had many scopo- 
lamin-morphin cases which he conducted in the pres- 
ence of the relatives of patients. 

" These audiences were often composed of the 
mother and the decidedly critical mother-in-law. 
Although my Dammerschlaf is not carried to the ex- 
tent of deep narcosis, I have never heard any fears 
expressed by the witnesses that the thing looked 
■* risky ' or ' alarming/ On the contrary, I have 
often heard the mother of a patient regret that Twi- 
light Sleep had not been developed twenty years 
earlier so that she might have enjoyed its comfort. 

" In every instance I have received the grateful 
thanks of the women who have seen their daughters 
delivered in Dammerschlaf. 

" In the wards where several women are delivered 
at once and the scopolamin-morphin births can there- 
fore be watched by women soon to become mothers 
themselves, these witnesses frequently beg me to 
promise that they shall later on have their ' needle ' 
too, which certainly proves the evident reduction of 
pain in the Twilight Sleep patient, observed by the 
onlookers, while it also must prove that these wit- 
nesses received no impression of heavy poisoning by 
scopolamine 

In 1 8 per cent, of his cases Preller attained no 
Dammerschlaf, but only a sleepy condition in which 



DR. PRELLER'S EXPERIENCE 149 

there was a considerable reduction of suffering. 
"In 12 per cent, the results were not satisfactory; 
this was (in the majority of cases) due to a too rapid 
progress of birth which did not give us time to pro- 
duce a Dammerschlaf ; in the minority of our fail- 
ures we desisted from further injections on account 
of observing symptoms of poisoning in the patient. 

" However, from the patienfs own subjective 
point of view we only failed in 4 per cent, of all 
cases. 

" Only two mothers expressed dissatisfaction with 
the method. Both these women complained during 
and after birth of a dull feeling in the head and a 
paralyzing heaviness of the limbs. 

" In the rest of our cases total amnesia from the 
subjective point of view was a complete success." 

There were among his 120 cases only two in- 
stances of hallucinations. Excitement and agitation 
were sometimes observed during the actual pains. 
The pulse and breathing were regular. After the 
delivery, both mother and child slept soundly and 
woke up refreshed and without any after effects. 

Of the concomitant effects of scopolamin noticed 
by Preller, he first mentioned an undoubted effect 
upon the heart. " In 20-25 per cent, of all cases 
there was a distinct effect, though not always of an 
unfavorable nature. The injections at first cause 



150 THE TRUTH ABOUT TWILIGHT SLEEP 

a more voluminous and regular pulse. Whenever I 
found the heartbeats increasing to 120 or 130 per 
minute with irregularity or inequality, I regarded it 
as a warning to desist from further injections or to 
wait at least for a considerable length of time before 
proceeding. For this reason I never had any seri- 
ous consequences. 

" I do not, however, believe Hocheisen's case of 
disturbance of the heart action was due to scopo- 
lamin. I have regularly observed that all symptoms 
of disturbed circulation quickly disappear. 

" Respiration was never seriously disturbed, prob- 
ably because of our cautious calculation of doses. 
Neither have I ever noticed any effect upon the kid- 
neys. In one Dammerschlaf case the patient had 
nephritis gravidarum" (kidney disease )"with al- 
bumen in the urine; during the beginning of birth 
there were symptoms of uremia, but these symptoms 
diminished soon after birth. 

" I believe from my observations that labor and 
abdominal action are certainly retarded by scopo- 
lamin-morphin. Gauss is of the opinion that any 
diminution of abdominal action is due to too large a 
dose of morphin. 

" On the whole, we found the birth process unin- 
terrupted by the injections. 



DR. PRELLER'S EXPERIENCE 151 

" In 30 per cent, a change in the type of labor was 
noticed, in 16 per cent, of these cases labor was regu- 
lated and bettered, in the remaining 24 per cent, the 
vigor of labor was diminished, the pains less fre- 
quent and of shorter duration. 

" In 18.6 per cent, of all cases the labor pains were 
unchanged, in 6 per cent, they were increased." 
Preller thinks it only fair to remember that in births 
without scopolamin the variations in labor are just 
as evident, but he feels justified in considering the 
weakening of labor, in cases where such weakening 
occurred, due to scopolamin-morphin in 1 5 to 20 per 
cent. 

" There is however," he adds, " so much varia- 
tion in the average duration of birth process that 
only by the observation of thousands of cases could 
a decision be reached. On the whole, my impres- 
sion is that the protraction of birth by scopolamin- 
morphin is only slight." 

In cases where the deliveries were extremely dif- 
ficult, Preller says the patients " after delivery under 
the narcosis were much stronger and fresher than 
patients who had ordinary deliveries without injec- 
tions." 

He found that scopolamin-morphin had no ef- 
fect upon the milk secretion. 



152 THE TRUTH ABOUT TWILIGHT SLEEP 

THE CHILD 

Preller takes the matter of oligopnea much more 
lightly than even Gauss does. 

His views coincide with the opinion of an Ameri- 
can doctor who said to me the day before I left 
Freiburg : " I no longer regard the oligopneic con- 
dition of the child as serious. The fact that the 
babies are once in awhile born in this slightly in- 
toxicated condition from which they soon emerge un- 
injured, should not cause a doctor to condemn the 
method." 

Even Steffen, as we will see in the next chapter, 
believes " anxiety superfluous " in regard to the oli- 
gopneic condition of the baby. 

As a matter of fact, in Germany there is only one 
death of a child in the entire nine years of scopo- 
lamin-morphin records, which is accepted by most of 
the medical profession as a death due to scopolamin 
— this is the death of a child reported by Dr. Oscar 
Bass of the Chrobak Klinik of Venice. This child 
died from heart collapse after bathing. It is al- 
ways referred to in German medical journals as 
"the" death. 

A very reassuring and significant fact is that the 
statistics of the death rate of infants at the Frei- 
burg Frauenklinik (where all mothers have the 



DR. PRELLER'S EXPERIENCE 153 

Dammerschlaf ) is much lower than the general mor- 
tality of infants in Freiburg born outside the 
clinic. 

Furthermore, the infant mortality in Gauss's 
1,000 cases was markedly less than the Frauenklinik 
statistics showed the average of the ten years pre- 
ceding to have been. 

Preller reports his results to have been " very sat- 
isfactory as far as the children were concerned. To 
include the statistics of my predecessor, in all our 
220 scopolamin births we only lost one child and 
that was delivered with forceps because of its heart 
sounds and fear for the mother. 

"Among my 120 children we had only 6 apneic 
children and that was in the beginning of experi- 
ments. Almost 25 per cent, showed the character- 
istic symptoms of intoxication described by Gauss 
as oligopnea. 

"If these children are let alone they will fall 
asleep after from five to thirty minutes and they 
sleep off the intoxication, awakening fresh and cry- 
ing lustily. If the condition should, however, get 
worse, the oligopnea changing into apnea, simple 
tickling of the child is sufficient interference on the 
part of the doctor. 

" One child was born asphyxiated, but scopo- 
lamin was not the cause. 



154 THE TRUTH ABOUT TWILIGHT SLEEP 

" No lasting injuries to the child were observed, 
and they have always been found to develop well." 

As a prelude to Preller's final remarks, I should 
like to quote again Dr. Buist. In reply to the ques- 
tion, " What advantage has the Dammerschlaf 
method over the old obstetric anesthesia ? " he an- 
swered : " It places a much less fatiguing method 
at the disposal of the obstetrician." 

Preller's closing words are : " Scopolamin-mor- 
phin will probably find its only sphere of usefulness 
in the clinic, where there will always be doctors and 
a trained staff to cope with the dangers of overdos- 
ing and the requirements of the method. 

" If a private practitioner wants to try Twilight 
Sleep among his patients outside the clinic, he may 
do so only after having closely studied the peculiari- 
ties of scopolamin-morphin and its dosage; such 
study will only be possible at a clink. 

" Last but not least, he will have to give sufficient 
time to carefully watch the patient's condition after 
the injections; on no account should this condition 
be treated lightly." 



IX 



Several German Reports and a Wonderful 
American Experiment 

OF the reports of the opposition which I have 
translated, in none have I been more im- 
pressed with the absolute sincerity of purpose than 
in Steffen's. 1 He made a conscientious effort to 
carry out the Gauss instructions, as far as he could, 
and only departed therefrom when the condition of 
mother or child demanded that he, as a responsible 
physician, should so depart. 

Geheimrath Leopold, Steffen's chief, was so in- 
terested in the first Gauss report and so determined 
to give the method the largest possible chance to 
succeed, that he continued to urge Steffen to further 
experiments long after Steffen himself desired to 
abandon them, because of results. There was no 
preexisting prejudice to the method in the mind of 
either Leopold or Steffen, though Kronig in his pub- 

1 "On the Effect of Scopolamin-Morphin in Childbirth," by 
Dr. W. Steffen, Assistant of the Royal Frauenklinik of 
Dresden. Archives for Gynecology, Berlin, 1907. 

155 



156 THE TRUTH ABOUT TWILIGHT SLEEP 

lication of 1908 says: " Steffen, on the occasion 
of a discussion about the reduction of pain, said that 
he had never felt any necessity for lessening the pain 
felt by women in childbirth. This is only to be ex- 
plained by the fact that he is either quite callous or 
that when the screams and groans of women be- 
come too loud he left the room." If this was 
StefTen's individual opinion about the importance 
of lessening the pain, it is all the more praiseworthy 
that he completely put aside his own opinion on 
physiological pain and made every effort to carry to 
success the adoption of the Gauss method of " pain- 
less birth " at the Royal Frauenklinik of Dresden. 

He remarks in the beginning that the fact that it 
was only used in 300 cases is significant, for had it 
proved the ideal method Gauss described he would 
have continued it indefinitely. 

" At first we gave every woman in labor the first 
dose stated by Gauss to be the correct one, except 
in those cases where the necessity of an operation 
was evident on receiving the patient. The incal- 
culable side effects soon forced us to make a selec- 
tion of patients, excluding all cases of narrow 
pelvis 2 or cases where protracted and difficult birth 

2 The pelvis is that bony basin composed of hips and the 
lower bones of the spine, which hold the bowels, bladder, and 
the organs of generation. 



SEVERAL GERMAN REPORTS 157 

was expected, otherwise the necessity of an opera- 
tive termination might easily and unjustly have been 
ascribed to the use of scopolamin and morphin. 

" In the normal cases we gave the scopolamin 
injections at the beginning of labor pains and often 
witnessed the quickly slackening labor which did 
not develop again regularly. In such cases we did 
not give further doses, as the labor stopped by one 
injection did not recommence and the use of forceps 
became necessary to save the child. Eventually we 
only used the scopolamin-morphin injections when 
the child's head having already arrived at the lower 
end of pelvis, the labor had almost fulfilled its task 
and it was only a question of a few contractions to 
expel the child. But even then the muscles often 
refused to act further and we had to use either for- 
ceps or the Kristeller hand method. 

" The sensation of pain during labor is generally 
lessened. During the intervals of pains the mother 
is slightly asleep, awakening at beginning of pain 
or when spoken to. During the action of the mus- 
cles she is awake, and when told to do so she will 
cooperate, but she does not obey so readily when 
told to cease cooperation, rendering it thereby more 
difficult to protect the skin from tearing than in the 
case of a mother whose brain function is not dis- 
turbed by narcotic effects and who is, therefore, 



158 THE TRUTH ABOUT TWILIGHT SLEEP 

able to cease assistance, in spite of the stimulus of 
the pain of birth. When it becomes necessary to 
assist by hand, the mother resists and strains in the 
opposite direction as her mind is not clear enough 
to accept the explanation that manual assistance by 
the doctor is necessary. These are conditions in 
our group of favorable births. 

" In the unfavorable cases, where there is no mus- 
cular action the variable heart sounds of the child 
necessitate speedy termination of the birth ; the child 
is then born in oligopneic condition. Its heart is 
beating, it gasps once or twice, then lies motionless ; 
tickling of the skin is without result. The experi- 
menter knows that this apparently serious condition 
is only temporary; he puts the child in a bath and 
observes that it begins to breathe regularly but su- 
perficially. The narcosis wears off after from ten 
to fifteen minutes and the child opens its eyes and 
begins to cry. The inexperienced physician takes 
great trouble to resuscitate the child, but we believe 
anxiety is superfluous. For the spectator, the ap- 
pearance of the oligopneic child is alarming, and in 
private practise the midwife would undoubtedly 
urge the doctor to make hurried efforts at resusci- 
tation. 

" Instead of scopolamin-morphin having a quiet- 
ing effect on the nerves of the mother, the patient 



SEVERAL GERMAN REPORTS 159 

often reacts upon the first usual dose very violently, 
talking confusedly of home and husband, even be- 
traying family secrets. Gauss acknowledges that 
in seven of his cases the hands of women had to be 
tied. 

" We succeeded sometimes only after five or six 
doses in putting patients to sleep. Considering the 
dangerous character of this chemical, the physician 
then has the disagreeable sensation of wondering if 
the patient will ever wake up again or not. Our 
injections were rarely given at intervals of less than 
two hours, often from three to six hours, always 
using the memory test as instructed by Gauss. We 
were, however, principally guided in our doses by 
the closest observation of the heart sounds of the 
child. To this fact we owe our low number of 
oligopneic children — 18.8 per cent.; while in 
Gauss's first 500 cases he had 36.8 per cent., and in 
his following 500, just reported upon, he still had 
19 per cent. 

" I am convinced that after a long action of the 
poison the integrity of the nerve cells is disinte- 
grated, which fact is not unimportant for the later 
well-being of the mother. Some might object that 
such injuries are present in every narcosis, and the 
accumulating dangerous effects are generally well 
known; to this we might reply, narcosis in general 



160 THE TRUTH ABOUT TWILIGHT SLEEP 

is only undertaken for absolutely unavoidably neces- 
sary reasons. 

" We did not use the blue glasses, or antiphones 
for the ears, out of consideration for our assistants, 
because of the repulsiveness of the picture pre- 
sented.' ' 

This seems a rather poor excuse for omitting this 
precaution urged by Gauss. 

" The agitating effect of scopolamin, resulting in 
slight irritation of sight and hearing, are apt to be 
magnified phantastically and give rise to illusions. 
I consider this a great defect of the scopolamin 
method. 

" It was when this present work was in progress 
that there was published by Gauss in the Munich 
Medical Weekly his report on his first 1,000 births 
in Dammerschlaf, and in this he now describes the 
apatropin test of scopolamin solutions. This test 
was not known to us in the above 300 cases. The 
fact that Gauss objected to the freshly prepared so- 
lutions of the apothecary of the Berlin Charite 
caused me to go personally to various apothecaries, 
giving clear instructions about the importance of 
the most carefully prepared solutions. These solu- 
tions were then tested daily in the manner prescribed 
by Gauss with solutions of calcium permanganate. 
In a further group of 20 cases, in which these solu- 



SEVERAL GERMAN REPORTS 161 

tions were used, we had, however, to desist from 
further injections when danger to the child appeared 
to be present. These cases were observed by me 
as well as by Dr. Richter, Dr. Leisewitz, and three 
assistants. The careful memory test observations 
of the state of clouded consciousness and retrograde 
amnesia were carried out mostly by myself. In no 
cases were the midwives or students charged with 
the observations, or the memory test. At the bed- 
side of every patient, however, there was a student 
who had to take notes of the duration of each pain 
and the intensity of same ; the progress of the birth 
and side effects being judged by the doctors. 

" It is interesting to note that in one case where 
no scopolamin-morphin injections were used on the 
mother, she became confused in mind, did not ob- 
serve the birth, and asked if the doctors were going 
to perform an operation; apparently her memory 
had had an interruption without the use of scopola- 
min. It would be an interesting study to find out how 
often this is the case in entirely spontaneous births. 

" To illustrate the hallucinations caused by sco- 
polamin, I will give the following answers made by 
a mother : 

" Question : ' Why do you cry ? ' 

" Answer : ' Because I have no work/ 

" Q. : ' What is hurting you ? ' 



162 THE TRUTH ABOUT TWILIGHT SLEEP 



"A. 


"Q- 


"A. 


"Q. 


"A. 


aecl. 

"Q. 


"A. 


"Q. 


"A. 



' The pastry.' 

'Who am I? ' 

' The barber/ 

' Where is my barber shop ? ' 

' In the Z611nerplatz. , Afterwards she 

Frauenklinik.' 

' What did I show you just now? ' 

' Hats/ 

' Have you a child ? ' 

' Yes, the baby should be baptized/ Then 
she complained loudly : ' I can't stand it any longer. 
Is it not over yet ? ' 

" Q. : * What is the matter ? ' 

' Income.' Then she added : ' Dresden 

(a suburb of Dresden). 

' What is hurting you ? ' 

' Down my neck and finger tips/ She 
complained and cried loudly when the child was 
born : ' Oh, that hurts ! ' Afterward she has no 
memory of anything! 

" To make a resume of the first 300 and the last 
20 cases, we find that in many cases scopolamin- 
morphin does not show the desirable effect of oblit- 
erating the suffering of pain at birth, or the facili- 
tation of the act of birth by producing a state of 
sleep, although it leads to a lessening and dulling 
of sensitiveness in a minority of the cases; on the 



"A.: 
Altstadt 

"Q.: 

"A.: 



SEVERAL GERMAN REPORTS 163 

other hand, in the majority of the cases, unfavor- 
able effects are produced by diminution of labor 
action down to entire stoppage, variation of the in- 
fant's heart sounds, oligopneic or apneic condition 
of child, and often an increase of sensitiveness to 
pain, unrest, and confusion of mother with hallu- 
cinations to the point of delirium. We cannot, 
therefore, recognize the use of scopolamin-morphin 
in obstetrics as described by Gauss, but we think 
(1) the effect of scopolamin-morphin does not ob- 
tain the object aimed at; (2) it is not without 
danger to mother and child; (3) it is not to be 
recommended in private practise, especially because 
the doctor must be present every moment on ac- 
count of the incalculable side effects of the drug." 

I have felt it necessary to give extremely exhaus- 
tive accounts of the failures of Hocheisen and Stef- 
fen, for the reports of these two obstetricians are 
still to-day the most largely quoted by all authori- 
ties who desire to prove a case against Twilight 
Sleep. 

Hocheisen's failure is easily explained by a close 
study of his careless technic, but Steffen's is not to 
be dismissed. I have reread the Steffen report five 
times since my first translation of it from the Ger- 
man, hoping each time that I might find some ex- 
planation for his failure in an oversight somewhere 






164 THE TRUTH ABOUT TWILIGHT SLEEP 

of the Gauss instructions, or in a miscalculation of 
dose. 

Steffen leaves himself open to criticism on this 
point: He states that eventually he did not give 
the injections until " it was only a question of a few 
contractions to expel the child." Under the circum- 
stances it could certainly be argued that he could 
not possibly then have had time to establish a 
Dammerschlaf at all, which would easily account 
for his statement that in many cases " scopolamin- 
morphin does not show the desirable effect of ob- 
literating pain at birth." 

Furthermore, many obstetricians warn against 
making the injections too soon before the actual 
birth, as in that case the child is very apt to be im- 
pregnated with the drugs transmitted from the 
mother to child through the placenta and is more 
liable to be born in an oligopneic condition. 

Still another point ; Tichauer says : " Gauss has 
clearly indicated that absolute painlessness is not 
aimed at and when it occurs it oversteps the limits 
of Dammerschlaf and indicates an overdose ; yet we 
find that Steffen obtained painlessness (unconscious- 
ness) in 45.8 per cent, of his cases." 

Mans f eld says : " As soon as painlessness is 
aimed at there is danger of overdosing." 

But aside from these few assailable points, after 



SEVERAL GERMAN REPORTS 165 

closest study of the Steffen report I can only say 
I am still convinced he gave the method a consci- 
entious trial; his failure is therefore to be treated 
with serious consideration. 

The only other important Continental reports of 
this year are those of Gminder, Bass, and Holzbach. 

It does not seem necessary to give the report of 
Dr. Gminder, 3 as all value of his record as a cri- 
terion by which to judge the method is nullified by 
the fact that he in no way adhered to the rules of 
Gauss, either in regard to the dosage or the memory 
test. 

He says : " Gauss has included a new factor by 
which to judge the stage of narcosis — the memory 
test. I may as well underscore right here that by 
* sufficient effect of drug ' I understand painlessness 
of labor without interruption of the progress of 
birth. I did not adhere to the memory test, as I 
wanted to find the best way in which the best results 
could be obtained without injury to mother and 
child." 

Small regard for either mother or child was 
shown by Gminder in the amazing experimental 
doses indulged in by him. This record is one of 

3 " One Hundred Cases of Scopolamin-Morphin Narcosis 
in Obstetrics." From a speech made by Gminder of Krupp's 
Hospital at Essen, at the Society of Medicine at Essen, 1907. 



166 THE TRUTH ABOUT TWILIGHT SLEEP 

the best proofs ever furnished of the comparative 
harmlessness of scopolamin, for had this drug the 
deadly qualities ascribed to it by some writers, one 
cannot but believe Gminder's list of casualties would 
have been large. 

As Tichauer says : " It is a marvel Gminder's 
results were not worse, and, to crown it all, old solu- 
tions were often used." 

In only 20 cases did he make the slightest pre- 
tense of adhering to the Gauss dose; in the other 
instances he kept varying the dose with and without 
morphin in groups of three, five, eight, or eleven 
patients, employing in each group an entirely differ- 
ent technic. Yet Gminder has the effrontery to 
bunch the results of all these dissimilar experiments 
under one head and give them as the record oi an 
experiment with the Gauss Dammerschlaf. 

After such reckless experimentation it is astound- 
ing to find that out of his 100 cases he reports 58 
satisfactory births. 

Gminder's report really constitutes a sort of sco- 
polamin-morphin vaudeville. 

The use of the term tc ,rmwiarcosis " in Dr. 
Bass's 4 title is significant and indicative of his care- 
ful observance of rules. 

4 " One Hundred and Seven Births under Scopolamin-Mor- 



SEVERAL GERMAN REPORTS 167 

Of the operations necessary in his cases, Bass 
declares " not one was directly or indirectly con- 
nected with the narcosis." 

As to the length of birth, he says : " Although 
there was no case where protraction of birth could 
not otherwise be sufficiently explained, still it seems 
to me that scopolamin-morphin influenced the pro- 
cess of birth if but only slightly. However, inter- 
mission of labor will happen in all protracted 
births." 

Bass's report is particularly just and lacking in 
prejudice or conclusive opinions, as he says, " the 
publications on this narcosis vary so greatly as to 
the value of the method, it is as yet impossible to 
form a definite opinion." His own experience 
nevertheless was decidedly in favor of Twilight 
Sleep. 

Holzbach 5 at this time made interesting experi- 
ments to answer the following questions : 

(1) Is scopolamin excreted or is it still circu- 
lating in the body of the child? 

(2) Does it still circulate in the body of the 
mother ? 

phin Semi-narcosis," by Dr. Oscar Bass of the Crobak Clinic, 
Vienna. Munch. Med. Woch., 1907. 

5 " About the Relations of Scopolamin to Child During and 
After Birth," by E. Holzbach. Munich Med. Journal, 1907. 



168 THE TRUTH ABOUT TWILIGHT SLEEP 

(3) Is it introduced into the child through the 
mother's milk? 

Chemical test was not found to be sufficient, so 
Holzbach had to make the more sharp physiological 
experiments. 

" After ascertaining the smallest quantity of sco- 
polamin which would dilate the pupil of the eye, I 
then took milk from the mother, who had received 
injections at birth, and instilled three drops of this 
milk into the human eye. These experiments, as 
well as those made with the urine of the new-born, 
did not prove the presence of scopolamine 

He then followed with experiments upon the 
much more sensitive eye of the frog and proved the 
presence of scopolamin in the mother's milk. Holz- 
bach thereupon comes to the conclusion that sco- 
polamin is still present in the mother during the 
first few days after birth. 

The urine of the child immediately after birth 
showed the presence of scopolamin, but it was found 
to have been excreted through the kidneys after one 
quarter of an hour. 

Salzberger, 6 commenting in 19 10 on the Holzbach 
tests, says: 

6 " On Danger to Children from Scopolamin-morphin Ad- 
ministered During Birth," by Dr. Max Salzberger of Kulm. 
Inaugural Dissertation. Published 19 10. 



SEVERAL GERMAN REPORTS 169 

"If this small quantity of the drug proved to be 
present in the mother's milk up to the third day, 
were injected hypodermically, it would produce no 
effect upon the child, how much less effect then 
could it have when taken internally." 

Of all the sixty-nine reports on Twilight Sleep 
gathered from world-wide sources, no report has 
given me quite the thrill of pleasure which that of 
Dr. Birchmore of Brooklyn, N. Y., produced. 

It is especially significant that this report was 
published in June, 1907, at a time when it took a 
brave man to sound the praise of scopolamin-mor- 
phin in the States, for it was at a period when only 
a few other American physicians were making tim- 
orous experiments with these drugs with general 
resultant failures, after which the method was 
quickly discarded and damned. In view of all this, 
I think the women of America should feel a vast 
and deep gratitude to Dr. Birchmore and his name 
should be handed down among them as the Ameri- 
can pioneer of Painless Childbirth and the first 
champion of the cause of Twilight Sleep. 

My attention was drawn to this report in Ger- 
many where it is a prized contribution to the cause 
of Twilight Sleep; my first transcription of it was 
from the excerpts contained in the reviews of the 



lyo THE TRUTH ABOUT TWILIGHT SLEEP 

record in the German medical journals, but after 
my return to England I got the report in its entirety 
at the library of the British Medical Association. 

Dr. Birchmore's opening words are : 7 

" Since the rediscovery of the condition under 
which the deep sleep resembling death in its sound- 
ness — of which the tradition has come down the 
ages — could be procured, men in various parts of 
the world have made use of it to obtain insensibility 
to pain. ,, 

He continues in speaking of scopolamin (or 
hyoscin) : 

" I believe, as a statement of the conditions, in 
fact and in practise, on which that great improve- 
ment in the obstetric art for which we have long 
been looking may reasonably be grounded. The 
actual results which have been attained may be sum- 
marily stated in a few words : the patient slept, labor 
came on, and progressed in accord with usual con- 
ditions, normally in relation to the details. 

" The labor was not prolonged — far otherwise 
and in no case was it needful to use an anesthetic, 
although the forceps was used thrice. 

" The only case in which the mother showed any 

7 "The Hyoscin Sleep in Obstetric Practise," by Wood- 
bridge Hall Birchmore, M.D., Brooklyn, N. Y., 163 Fulton 
Street. Medical Record, Vol. 71, June, 1907. 



SEVERAL GERMAN REPORTS 171 

signs of awakening was not one demanding inter- 
ference." 

How delightful to read the following concerning 
the babies : 

" No results influencing the infant unfavorably 
were observed, although most anxiously looked for." 

Dr. Birchmore's dosage was as follows: 

" The hyoscin (or scopolamin) was administered 
in doses of %oo of a grain + % of a grain of mor- 
phin and cactin %7 of a grain. This amount was 
given in solution of 1 c.c. of water and repeated as 
required." 

The quantity most usually employed for the first 
injection by the British doctors to-day is very nearly 
that given by Dr. Birchmore, the British doses gen- 
erally being Koo of a grain of scopolamin to % of a 
grain of morphin. 

One one-hundredth of a grain equals .00065 g- 
and % of a grain of morphin equals .01 g. morphin; 
which, you see, makes the British doses practically 
the same as those employed by Gauss. 

Dr. Birchmore says much stress should be laid on 
the purity of the ingredients, for obvious reasons; 
it being of special importance when so small a dose 
of scopolamin is used that the most absolute purity 
be attained. 

" The first dose was given as soon as the first 



172 THE TRUTH ABOUT TWILIGHT SLEEP 

stage of labor was certainly beginning and was in 
most cases sufficient to hold the patient until the 
so-called impulsive pains were distinctly pro- 
nounced." 

Dr. Birchmore employs the Gauss memory test, 
for he says : 

" The instant the patient began to show the least 
evidence of perception, the second dose was given. 
In the cases requiring the forceps a third dose was 
given in two instances but not in the third case." 

It is interesting to find the uniformity of effect 
upon the patients noted by Dr. Birchmore, for he 
says the patients did not show the variation which 
might in some cases have been expected, the results 
being the same as far as the depth of sleep and the 
continuance of it was concerned, nor did he find 
that the injections had a cumulative effect upon the 
mothers. 

In one group of cases the average duration of the 
nap was six hours, while in another group the sleep 
continued for eight hours, from the time the second 
injection was given. 

He tells an amusing case of one woman on whom 
the injection had the peculiar apparent effect of 
causing great activity on the part of the unborn 
child. 

This mother repeatedly declared : 



SEVERAL GERMAN REPORTS 173 

" This child kicks something awful ! " 

The child continued to behave in this recalcitrant 
and impolite manner for four hours after the injec- 
tion was given. The mother then slept for five 
hours and she said on awakening that the child had 
ceased to kick, but in a few hours the boy recom- 
menced his exercises and continued to cause his 
mother discomfort for some time. 

The mother humorously remarked to the doctor : 
"If he is such a kicker all his life, he will make 
lots of trouble." 

The patient having received a second injection 
at the beginning of real labor then " slept until after 
the birth of her child, becoming somewhat restless 
at the end but not regaining consciousness until 
after the baby had been cared for and all provisions 
made for the comfort of the mother." 

In one case the baby was born sleepy, but Dr. 
Birchmore says proof that the drug caused this con- 
dition was not positively established. 

" All direct evidences of long continued interfer- 
ence with the actions of the child after birth is want- 
ing and in only one instance was an effect upon a 
child positively affirmed by another doctor attend- 
ing. 

" Apart from the influence upon the direct prog- 
ress of the labor, the effect upon the mother was 



174 THE TRUTH ABOUT TWILIGHT SLEEP 

most noteworthy ; first, as quite hindering the men- 
tal disturbance which pain and suffering in all cases 
produce." This is indeed a noteworthy fact and 
one on which Dr. Kronig has always laid such 
stress. 

The next sentence of Dr. Birchmore is of the 
greatest interest to mothers; he says one physician 
remarked after using scopolamin-morphin : 

" Objectively, as evidenced by the mother's con- 
dition, it appeared a preposterous proposition to say 
that she had given birth to a child.' ' 

Another very important point is the lack of re- 
sistance in the mother to the efforts of nature to 
expel the child. Quieted by the narcotic, and men- 
tally without apperception of the agony of the work- 
ings of the expulsion muscles, she makes no effort 
to check the full force of the contractions of those 
muscles. 

To quote Dr. Birchmore : " The mother shows 
no signs of exhaustion, and although the passive 
resistance of the tissues must be quite the same, it 
can be clearly seen that no spasmodic resistance, by 
inhibition due to pain, in any way interferes. This 
absence of the active resistance is perhaps the most 
remarkable effect produced." 

As an example of the beneficial results of muscles 
working independently of mental suffering, he tells 



SEVERAL GERMAN REPORTS 175 

of one mother who, after a labor that had been not- 
ably tedious, was delivered of her fourth and 
largest child in less than two-thirds of the time of 
the shortest of her former experiences in childbirth, 
and in one-third the length of time of her longest. 
She had always in former births been peculiarly 
restless and difficult to manage, but with scopo- 
lamin-morphin she " simply slept through the whole 
series of phenomena; she did not awaken until she 
had been removed to a clean bed and provided with 
all things needful." 

Now read with deliberate care the revelations 
contained in the following: "At the birth of the 
head, although soundly sleeping, she made certain 
spasmodic actions and changes of position which 
caused some surprise to the nurses and attending 
physician." 

Dr. Birchmore's conviction is that the following 
statements of the physician conducting this birth 
contain an important truth ; they are : " Her ac- 
tions showed that combined movements should 
occur which are inhibited " (prevented) " in the 
large majority of cases. It was as if I had seen the 
natural action of a woman for the first time." 

Telling of the amazing cooperation of the patient 
in Twilight Sleep, Dr. Birchmore cites two cases in 
which the mother " rolled on to the left side, partially 



176 THE TRUTH ABOUT TWILIGHT SLEEP 

flexed the left leg upon the thigh and the thigh upon 
the pelvis so that the child was or rather would have 
been supported and guided on to its back by the act 
of extrusion. The right lower extremity extended 
to the extreme, the toes pressed against the foot of 
the bed gave a ' fixed point ' for the muscular lev- 
erage." 

My only experience in midwifery has been with 
my goats — I formerly had a flock in Bermuda — 
and Dr. Birchmore's above description is a perfect 
description of the phenomena of nature in the sec- 
ond and third deliveries of kids by my goat mothers. 

The first time a goat bears kids she suffers too 
intensely for the normal action of nature, but in 
the second and third set of kids the leg is flexed 
just as Dr. Birchmore describes in his human pa- 
tient under scopolamin-morphin and the attitude of 
the mother-goat is precisely that which was evi- 
dently originally planned by nature to be the one 
taken by women in order that the child should be 
expelled correctly. 

Dr. Birchmore says in the majority of cases " the 
heels were brought against the buttocks and in these 
cases the muscles were made tense, lifting the but- 
tocks completely off the mattress at the instant of 
birth of head, yet there was no sign of awakening. 

"The steady, slowly increasing and tremendous 



SEVERAL GERMAN REPORTS 177 

force exerted by the abdominal muscles during the 
expulsive pains attracted the attention of all ob- 
servers. One who has seen great numbers of labors 
said that he never saw anything like it before, and 
added, in an extended opinion, that the great advan- 
tage over chloroform is easily seen, in that with the 
hyoscin (scopolamin) sleep reflexes are greatly aug- 
mented, not suppressed. 

" All who have made use of hyoscin a few times 
appear to regard this restoration of the truly natu- 
ral conditions as being of almost as much impor- 
tance as the unconsciousness from pain. 

" ' If we use hyoscin the mother cannot do mis- 
chief by her own excited and voluntary or semi- 
voluntary actions,' is a remark made by every user." 

As to rupture of the perineum (the space between 
the lower termination of the rectum and the vagina ), 
Dr. Birchmore says proof is wanting of this danger. 
One doctor said : 

" The rupture of the perineum, when not due to 
the haste of the accoucheur " (the obstetrician), " is 
due to the excitement of the mother. 

" From what I have seen I am inclined to regard 
the dilatation of the perineum much as I regard the 
dilatation of the uteri" (womb). "It is gradual 
and the obstruction, although usually needless now, 
must have been of importance once. The waking 



178 THE TRUTH ABOUT TWILIGHT SLEEP 

mother (without scopolamin-morphin) makes con- 
vulsive efforts to overcome the resistance of the 
perineum and when she feels the obstruction, has 
a titanic if not tetanic spasm to force the head by, 
and then the shoulder (of child) catches. But in 
hyoscin sleep the first perineal pains are not con- 
vulsive, and instead of one or two ineffectual at- 
tempts, ending almost in a convulsion, the sleeping 
woman has a dozen small pains gradually stretching 
the sphincter " (the circular muscle which opens and 
closes) " and besides this the head is not held so 
firmly against the sphincter, or rather against the 
fold of sub-mucous tendon, that this cannot roll and 
after once or twice trying the whole apparatus — 
tendons, muscles and mucous membrane — slips out 
of the way and the last expulsive pain comes on. 

" For my part I regard this use of hyoscin as im- 
portant because it has restored the conditions of 
normal labor. 

" I know my expression is bad," modestly de- 
clares Dr. Birchmore, " but, somehow, hyoscin gives 
the management of labor back to the reflex ganglia 
from which the brain in women had taken it away." 

As for the forceps cases, he says : " Certainly 
the use had no connection with the insensibility of 
the patient. All who have made use of this nar- 
cotic, without any exception, insist that exhaustion, 



SEVERAL GERMAN REPORTS 179 

even to a small degree, is hardly to be perceived. 
The absence of excitement, the regularity and above 
all the maturity of the expulsive efforts, the fact 
that none of the vitality of the mother is expended 
in useless and exhausting (because ineffectual) and 
disorderly efforts, promises to lessen greatly surgical 
interference — the special interference demanded by 
the mother's state. 

" The importance of the hyoscin sleep in obstetric 
practise is amply demonstrated, and experience 
shows that it can give us all the aid, in quieting the 
patient, that any narcotic can give, and in addition 
it gives us a practical anesthesia of prolonged dura- 
tion and gives this anesthesia without risk to either 
mother or child. Furthermore this: we have the 
most abundant proof that this practically anesthetic 
sleep is quite without danger, because the respira- 
tory system is in no way interfered with, nor is the 
heart action restrained. It is also clear that the 
reflex actions which find their point of departure 
peripherally" (from the outer surface) "and re- 
turn to the periphery again from spinal and sym- 
pathetic system ganglia, specifically from the ' pelvic 
brain'" (so named by Byron Robinson) "are not 
restrained, but rather they are augmented by the 
action of this drug. Clearly, then, it is a drug seda- 
tive to the cerebrospinal axis, but not to the ganglia 



180 THE TRUTH ABOUT TWILIGHT SLEEP 

connected with the reflexes of common life. This 
fact alone is of no trifling importance, but the im- 
port grows when we note that in shutting the door, 
so to say, to the influence of the inhibitory actions, 
it leaves quite unopposed the influence of the sym- 
pathetic system, and the physician using it need 
have no fear of any accidents to disturb the normal 
evolution of a birth. It is, then, for the accoucheur 
the ideal anesthetic, one which, so far as we yet 
know, he can use to obtain the desired effect without 
fear of an overdose. So far as I have been able 
to learn, no one has yet had any experience with 
excessive doses." 

What must Hocheisen, Gminder, and Steffen 
have thought when they read that ! 

" We certainly know that all we need to give can 
be given without risk or danger. 

" Finally, and perhaps of all the most important, 
this use of hyoscin has stripped motherhood of its 
horror. 

" The dread of pain has been the great dread of 
the coming birth ; until this discovery the ' pains of 
maternity ' remained a horrid and incontestable 
truth, but these have vanished and the exhaust- 
ing ordeal of motherhood is gone to be seen no 



SEVERAL GERMAN REPORTS 181 

This is by far the most important document con- 
cerning Twilight Sleep which has yet been written. 

It is a mystery why its convincing truths did not 
stir all American physicians to experiment with 
scopolamin-morphin ; it is, furthermore, amazing, 
after such successful results as those obtained by 
Dr. Birchmore, that American mothers, kept utterly 
in the dark about this important discovery, should 
have been forced to go abroad to find relief in a 
German Frauenklinik from the agony of childbirth. 

THE MOST SALIENT FACTS OF DR. BIRCHMORE's 
PAPER are: 

i. With the entry of scopolamin-morphin " the 
pains of maternity have vanished to be seen no 
more. ,, 

2. These drugs form " the ideal anesthetic." 

3. " This anesthetic is without risk to either 
mother or child." 

4. All who have used this method " without any 
exception insist that exhaustion even to a small de- 
gree is hardly to be perceived." 

5. The danger of perineal rupture is done away 
with. 

6. Scopolamin does not prolong the birth process 
— " far otherwise." 



182 THE TRUTH ABOUT TWILIGHT SLEEP 

7. " No results influencing the infant unfavorably 
were observed, although most anxiously looked for." 

8. That in Twilight Sleep there has been a " res- 
toration of the natural conditions " — this last is 
the most remarkable and important feature of all. 






X 

The Remarkable Reports of 1908 

KRONIG 

THE most important publication of this year 
was the report of an address made by Dr. 
Kronig, 1 director of the obstetrical department of 
the Freiburg Hospital for diseases of women. 

The entire present scopolamin-morphin method is 
due to Dr. Kronig's determined efforts — first at 
Jena and later on at Freiburg, where his assistant, 
Dr. Gauss, eventually perfected the Dammerschlaf 
under Kronig's direction. 

As Dr. Kronig stands sponsor for Twilight Sleep, 
many would perhaps like to know something about 
his history. 

He was born on the 27th of January, 1863, at 
Bielefeld, Germany. After attending the gym- 
nasiums (classical schools where Latin, Greek, etc., 

1 " Painless Delivery in Dammerschlaf," by Bernhardt 
Kronig, Ordenlicher Professor, Geheimrath, M.D. Deutsche 
Med. Wochenschr., No. 2s, 1908. 

183 



i84 THE TRUTH ABOUT TWILIGHT SLEEP 

are taught) at Bielefeld and Dessan, he then attended 
three universities — Heidelberg, Kiel, and Berlin. 

His professional career is as follows : he was first 
appointed assistant to Professor Pagenstecher at 
Elberf eld ; his next work was under Professor Hoffa 
at the Private Orthopedic Clinic at Wurtzburg, then 
in the laboratory of the Berlin Gynecological Hos- 
pital; his fourth position was at the Koch Institute 
and from there he went to the Leipsic Gynecological 
Hospital. 

At Leipsic in 1896 he was appointed Private-Doz- 
ent (authorized lecturer). There is in Germany a 
half-way stage between lecturer and sure-enough 
professor, which is called " Ausserordentlicher Pro- 
fessor/' but in Kronig's case he was promoted direct 
from lecturer to " Ordentlicher Professor" (the 
highest kind of professor) at Jena in 1903 and again 
at Freiburg, at the Ludwig Albrecht University in 
1904. 

Dr. Kronig is the author of many books on gyn- 
ecological subjects. 

So we see that the man who is responsible for the 
scopolaniin-morphin narcosis as used to-day, is a 
man of the most distinguished attainments, and the 
highest professional standing. 

In appearance he is a great blond giant with an 
enthusiastic profile. Kindliness radiates from all 






THE REMARKABLE REPORTS OF 1908 185 

his great frame. He has not one hardened emo- 
tion. 

He shed tears of sympathy over a young Ameri- 
can girl on whom he had found he must perform one 
of the most serious operations in the world. 

The Steffen report and the violent discussion 
which followed between Kronig on the one side and 
StefTen and Leopold of the Dresden Royal Frauen- 
klinik on the other, at the Seventy-ninth Meeting 
of the German Naturalists and Doctors, was so 
taken to heart by Dr. Kronig that he was actually 
made ill and was confined to bed for several days. 

It is not surprising to find this giant of the tender 
heart fighting so long and against such perpetual op- 
position for the relief of women's suffering. 

As I sat in his private office I felt that the room 
was an expression of the man — it is all in gray and 
gold; gray walls, floor and doors, curtains of pale 
gold, table cover of gold; on the walls are three steel 
engravings, one small painting and one framed auto- 
graph; two bronze figures — one that of a black- 
smith; a mahogany desk and a couch covered by a 
beautiful fur skin — this is the room to which 
women have come from every part of the world to 
see the man who could promise them relief from the 
torture of childbirth. 

This publication of Kronig's is notable as being 



186 THE TRUTH ABOUT TWILIGHT SLEEP 

his only paper on the subject of scopolamin-morphin, 
and his only reply to the opposition. 

Kronig points out that scarcely any physician 
would be able, after only a few trials, to obtain the 
same results which have been achieved at the Frei- 
burg Frauenklinik after long experience. It is 
therefore unfair to decry the method as a failure, if 
the Gauss results are not obtained by others in their 
early attempts; they should, on the contrary, make 
further unprejudiced study. 

" It must not be forgotten that it was only after a 
study extending over many years that we ourselves 
succeeded in obtaining our present success. The 
method demands concentrated attention on the part 
of the obstetric staff. 

" Thanks to the generosity of the Grand Duke of 
Baden we have now been able to triple the obstetric 
staff in the delivery ward and this has enabled us to 
perfect our method, giving it the widest possible 
application to all classes of the population. 

" I mention this intentionally,' ' says Kronig, " be- 
cause I am of the opinion that in hospitals with a 
large number of cases, our procedure can only be 
employed with any prospect of success when a com- 
plete administrative reorganization in the assign- 
ment of duty in the delivery ward, has been ef- 
fected. 



THE REMARKABLE REPORTS OF 1908 187 

" If, as is the case in large hospitals, the doctor on 
observation duty is relieved every twelve hours, the 
colleague who follows him will not be sufficiently 
well informed as to the condition of the various 
cases in labor, and failure is certain to ensue. 

" Consequently I do not consider it the result of 
chance that it is precisely in small hospitals that our 
method has been successfully adopted. It is also 
significant that in the large hospitals of Berlin and 
Dresden, where there are many thousand births a 
year, our procedure has proven a failure. 

" This is easy to understand when we remember 
that the surroundings of the patient have an impor- 
tance which should not be underrated. Sense im- 
pressions, loud noises, bright lights, all disturb the 
half consciousness." 

At the time Kronig wrote this paper, there had 
been fifteen hundred births under scopolamin at the 
clinic. In all that number only one mother died and 
when one reads the circumstances of the death it 
would seem as if even the most biased opponent 
could scarcely attribute it to the narcosis. 

Here are the details : The patient was a woman 
with narrow funnel-shaped pelvis. Very soon 
Kronig saw that Csesarean section was absolutely 
imperative. The husband of the patient absolutely 
refused to consent to this operation, and while 



188 THE TRUTH ABOUT TWILIGHT SLEEP 

Kronig was still urging the necessity, the uterus rup- 
tured; even then Kronig declared to the husband 
that his wife might be saved if he would permit an 
operation, but that permission still being withheld the 
woman bled to death. 2 

As for the duration of birth, Dr. Kronig says: 
" It is either not increased at all by scopolamin-mor- 
phin or else increased to a quite negligible extent. 
But even if, in a number of cases, the observation 
should show the birth prolonged by perhaps a half 
hour, I believe this consideration cannot possibly be 
seriously allowed to outweigh the great blessing 
which we confer on the mother by eliminating her 
pain. 

" One can only form an idea of the blessing of the 
method by hearing the statements of women who 
have borne children without anesthesia. 

" In the whole course of my career as a physician 
never have I harvested such a crop of gratitude as I 
have since I established the Dammerschlaf in deliv- 
eries." 

Now that many of Kronig' s and Gauss's oppo- 
nents began to acknowledge that the method held 
safety for the mother, they took refuge in the objec- 
tion that it was dangerous for the child. 

Kronig refers to the tests made by Holzbach 

2 This obdurate husband — an Italian — " emphasized his 



THE REMARKABLE REPORTS OF 1908 189 

(which we have already given) and says that they 
prove that even though scopolamin is shown to be 
present in the child in minute quantities, these tests 
also prove it to be eliminated from the child's organ- 
ism in a very short time. 

When Kronig's paper was written, the oligopneic 
condition of children at the Frauenklinik had been 
reduced to 10 per cent. " We prefer to wait quietly 
for the child to breathe naturally of its own accord, 
but if one desires to produce rapidly regular breath- 
ing, nothing beyond simple mechanical stimulus is 
necessary. 

" The fact that the mortality of our children, both 
during and after birth, has been decidedly dimin- 
ished since our use of scopolamin-morphin, refutes 
the prophecy that the mortality of babies would be 
increased by the oligopneic condition leading to 
asphyxia. 

" The last objection brought forward is that the 
child will later on be injured by scopolamin passed to 
it from the mother. Out of 305 births in our pri- 
vate wards we have been able to trace the greater 
number of children and we can absolutely refute the 
expectation, expressed in some quarters, that the 
children would display a higher death-rate during 

determination upon the assisting doctor," said Dr. Kronig, 
" by means of a knife which he held in his hand ! " 



190 THE TRUTH ABOUT TWILIGHT SLEEP 

the first year of life. We can also prove their later 
physical and mental development to be absolutely 
normal. 

" As for the objection now brought forward by 
our opponents, who find themselves driven into a 
corner, viz. : that the deleterious effect of scopolamin 
will only show itself in the mental development at 
the age between twenty and thirty, we cannot but 
feel that this shows what unfair standards are ap- 
plied, when it is a question of opposing a new 
method. 

" This is the more salient when we remember that 
obstetricians practising among the better classes use 
forceps in almost every other case and consequently 
in all these cases must employ anesthetics — chloro- 
form and ether — the transmission of which, from 
mother to child, has been proven. 

" In addition to this, take into account the not in- 
considerable injuries often inflicted on the brain of 
the child by the forceps. In hundreds of cases the 
forceps cause subdural hematoma and a pressure in- 
ward on the skull. 

" W r hen we consider all this we are compelled to 
ask in amazement why it occurs to no one to draw 
attention to the fact that the brain action of the child 
is injured in these innumerable forceps operations, 
while it is being maintained that extremely minute 



THE REMARKABLE REPORTS OF 1908 191 

quantities of scopolamin (which have been proven 
by Holzbach to disappear shortly after birth) influ- 
ence the brain action of the child up to an advanced 
age! 

" It is important to say here that even in our pri- 
vate wards we have not used the forceps for the re- 
lief of pain on a single occasion since the introduc- 
tion of the scopolamin-morphin method." 

THE KLEINERTZ REPORT 

Kleinertz, of Stuttgart, studied the scopolamin- 
morphin method for one year in Freiburg under Dr. 
Kronig; the results of his experiments are therefore 
of particular value. 

That the Dammerschlaf is now (1914) a perma- 
nent institution in the Stuttgart hospital, is of even 
stronger significance than this report, which only 
deals with the first experiments in 280 cases. 

Kleinertz says : 3 "As many others have pointed 
out the harmfulness of scopolamin-morphin, I wish 
to state that by strictly observing the Gauss in- 
structions we did not have any untoward inci- 
dents." 

In each case before giving injections he examined 

3 " Childbirth in the Scopolamin-morphin Dammerschlaf," by 
F. Kleinertz of the Stuttgart Hospital. Zentralbt. f. Gynak. 
Liepzig, 1908, XLII, 1387-1391. 



192 THE TRUTH ABOUT TWILIGHT SLEEP 

the heart and kidneys of patients, but he does not re- 
gard slight heart disturbances as a counter indica- 
tion. 

In some of his earliest cases he used a mixed nar- 
cosis, employing chloroform when the head ap- 
peared. 

He adhered to the Gauss initial dose of .00045 g. 
scopolamin, but gave .015 g. morphin. The second 
injection was made after three-quarters to one hour, 
" always conscientiously testing the memory of pa- 
tient" 

He found it important not to inject more than pre- 
scribed by Gauss in first dose or else weak labor 
would be occasioned. " For this reason the first in- 
jection requires absolute attention on the part of the 
obstetrician. The heart sounds of the child during 
period of expulsion must also be watched very 
closely. For this reason the method is only adapted 
to the clinic." 

Out of 280 mothers he succeeded in putting 213 in 
Dammerschlaf. Fourteen times no result, on ac- 
count of too rapid birth. Nineteen times no Dam- 
merschlaf was attainable. " There were 29 cases of 
necessary forceps, caused by conditions which had 
nothing to do with the use of scopolamin." 

Further on Kleinertz says : " There is no doubt 
that a diminution of labor may occur, especially if in- 



THE REMARKABLE REPORTS OF 1908 193 

jections are given in too quick succession, or too 
early, or when the dose is not properly calculated. 
If a strong injection is given during the period of ex- 
pulsion it is often noted that scopolamin, acting too 
violently, affects the muscles unfavorably; for this 
reason the method requires especial care, attention, 
and judgment during the period of expulsion." 4 

With regard to the length of birth, Kleinertz 
found it averaged, in the case of mothers bearing 
their first child, nineteen hours and forty-five min- 
utes. In other cases thirteen hours and nineteen 
minutes. 

In the 280 cases there were 282 children. Four 
babies which were delivered by forceps died; five 
died after birth " for various reasons not connected 
with scopolamin. The majority of the children 
were born in a normal condition, only a few were 
oligopneic and a few asphyctic. 

" Aside from complaints about thirst from dry- 
ness of throat and mouth, no harmful influence upon 
the mothers was noticed. No evil after effects were 
observed. 

" In one case we desisted from further injections 
because of pronounced heart disease of patient; yet, 

*This may explain some of Steffen's failures, for we must 
remember that he did not begin his injections until this criti- 
cal period had arrived. 



194 THE TRUTH ABOUT TWILIGHT SLEEP 

nevertheless, we obtained a lessening of the pain. 
None felt ill afterward." 

The average blood loss of mothers was found to 
be 502 g. Good contraction of the uterus. Scopo- 
lamin did not affect the nursing capacity of patients. 

" Mothers who had previously had children with- 
out scopolamin were the best test of the beneficent 
effect of the Twilight Sleep; these declared their 
after state of health, after birth under scopolamin- 
morphin, much better in comparison with former 
births." 

The children's after health was found in no way to 
be affected. 

Kleinertz exceeded the famous Gauss maximum 
dose of .00375 g. scopolamin + .03 g. morphin 
given in fifty-seven hours, by giving one patient 
twenty-one injections in twenty-nine hours, the total 
amount reaching .00585 g. scopolamin -f- .01 g. 
morphin, and yet had no bad results. 

" The only difficulty of the method lies in the 
chemical instability of scopolamin, which makes it 
sometimes necessary to throw away freshly made 
solutions." Of course this fault has now been prac- 
tically eliminated by the invariable scopolamin of 
Professor Straub. 

Kleinertz concludes this report of his entirely 
satisfactory experiments, by saying: "If the ob- 



THE REMARKABLE REPORTS OF 1908 195 

stetrician and his staff will give their time and great 
pains to follow strictly the rules laid down by Gauss, 
they will then have a method which obtains its ob- 
ject of decreasing the suffering at birth without 
danger to mother or injury to child." 

H. Kionka, of Jena, 5 now made physiological ex- 
periments with scopolamin with the result — as I 
have stated earlier — that he declared scopolamin 
was not injurious to the muscles of the heart. 

He feels that he can establish two salient facts, 
viz. : 

1. Variation in scopolamin's physical action does 
not mean variation in its effectiveness. 

2. There exists great difference in the reaction of 
individuals to the drug. 

MAYER 6 

Professor Stoeckel, head of the University 
Frauenklinik of Marburg, gave his assistant, Dr. 
Mayer, a chance to study the Freiburg method under 
Gauss, and Mayer reports on fifty cases afterward 
conducted by himself. 

& Therap. d. Gegenw. Berlin. 1908. No. 1, pages 11-17. 

6 " Scopolamin-morphin at Birth," by K. Mayer, assistant 
at University Frauenklinik at Marburg, A. L. Published in 
Zentralblatt fur Gynak, 1908. Liepzig. XXXII, pages 689- 
699. 



196 THE TRUTH ABOUT TWILIGHT SLEEP 

He waited until the child's head was firmly in the 
pelvis to avoid too long a duration of the Dam- 
merschlaf and the necessity for giving too large a 
dose. 

Mayer thinks all secondary effects are to be at- 
tributed to the decomposition of scopolamin — a dis- 
advantage now done away by the Straub prepara- 
tion. For this reason Mayer carefully tested all 
scopolamin before using, by the Kessel test of i per 
cent, calcium permanganate. 

His first injection was only .0003 g. scopolamin 
-f- .01 g. morphin in separate injections. 

" The task of the obstetrician," he says, " is now 
to calculate the dose in each case, so that, on the one 
hand, not too little scopolamin is given — as then no 
hypalgesia can be obtained — and, on the other hand, 
to avoid too large a dose which would result in com- 
plete narcosis." 

In his fifty cases only twice were the labor pains 
diminished, and " even in those instances it cannot 
be said that scopolamin caused it." 

A nurse measured the duration of all pains by 
holding one hand over the abdomen, while keeping 
time by the watch. " Only by such a test can a defi- 
nite opinion be formed." 

He found that when the patient still complained 



THE REMARKABLE REPORTS OF 1908 197 

about suffering in spite of being in a state of Dam- 
merschlaf, the cooperation of the abdominal muscles 
was considerably greater. 

" Toward the end of the birth period the patient 
often has to be energetically urged to cooperate. It 
might be supposed, in a case where the head takes 
long in passage, because of lack of cooperation on the 
mother's part, that there would be indication for the 
use of forceps because of danger to the infant's life, 
yet among our fifty cases we had only one such 
case. 

" The violent hemorrhages ascribed by others to 
scopolamin were not observed by us. In thirty-five 
instances there was a loss of blood up to 500 g. In 
no instance did we have to use tampons." 

I want to draw your especial attention to the fol- 
lowing statement of Mayer, as I believe it to be of 
great importance. 

" We noticed a greater loss of blood in the cases 
where, because of the rapid expulsion, the first in- 
jection had only just been made. Where the scopo- 
lamin had been acting for some time the blood loss 
was less." 

Of the side effects, Mayer says that sometimes the 
patient became excited by scopolamin and wrestled 
with the nurse who was trying to protect the pe- 



198 THE TRUTH ABOUT TWILIGHT SLEEP 

rineum from tearing, so that it was impossible to 
guarantee complete asepsis (exemption from blood- 
poisoning or disease germs). 

He had one case where the woman showed strong 
idiosyncrasy for the drug and behaved madly after 
.0005 g. scopolamin had been injected within three 
and a half hours — a very small dose. She was in a 
deep Dammerschlaf, and in spite of having to be held 
by several persons during birth, half an hour after 
birth she came to and did not know she had become 
a mother. 

Another disagreeable feature noticed by him was 
painful thirst. " Often the only word uttered by 
patients who awaken during pains is ' water/ which 
they repeat over and over." He had only two cases 
of moderate vomiting. 

No after effects lasting until the following day 
were ever observed. 

There were three oligopneic children, and Mayer 
describes their condition as follows : " The chil- 
dren appeared rosy and fresh, their heartbeats some- 
what slow, but they did not cry, the breath was so 
superficial that no respiratory movement could be 
seen ; once in a while they opened their eyes. This 
condition need not create any anxiety in the spec- 
tator, as perhaps a minute or two later normal 
breathing sets in." 



THE REMARKABLE REPORTS OF 1908 199 

In the case of these children, Dammerschlaf had 
had to be attained in from three and a half to twelve 
hours. 

There was one apneic child (that is to say, a deep- 
ened state of oligopnea). In this birth — one of 
difficult extraction — .0016 g. scopolamin + .02 g. 
morphin had been given within six hours. " This 
case," says Mayer, " characterizes the narcotic effect 
of large doses of scopolamin upon the child's breath- 
ing center." 

As Gauss has pointed out, an oligopneic child al- 
ways indicates a miscalculated overdosing of the 
mother. As the technic of the doctor improves, 
the per cent, of oligopnea is correspondingly low- 
ered. 

In Mayer's cases, forty-five children (90 per 
cent.) were lively, and no abnormal behavior on the 
part of the babies, during their first days of life, was 
observed. 

To make a resume of Mayer's 50 cases: In 23 
he obtained complete Dammerschlaf. In 21 hypal- 
gesia. In 6 cases no effect. 

He explains his high per cent, of hypalgesia (par- 
tial painlessness) by saying: "In these cases we 
tried to obtain results with as small doses as possible, 
also in many instances the period of expulsion was 
so short it was impossible to make the repeated in- 



200 THE TRUTH ABOUT TWILIGHT SLEEP 

jections necessary for attaining a state of Dam- 
merschlaf." 

Mayer agrees with many others that the use of the 
drug in obstetrics can only be carried out in clinics 
where there is continuous superintendence of the pa- 
tients by doctors. 

He ends thus : " We may describe the method as 
a very remarkable attempt to lessen the suffering of 
women at birth, and we must fully recognize the 
merit of those who have taken great pains to develop 
Twilight Sleep, but we are, however, of the opinion 
that the scopolamin-morphin method does not quite 
attain its object, viz. : the reduction or abolition of 
pain at birth, and that the application of the in- 
jections is bound by too narrow time limits. ,, 

After having attained complete painlessness in 23 
cases and lessened pain in 21 (making 44 cases of 
reduced pain in 50 births), it seems rather incon- 
sistent for Mayer then to say the method fails in its 
object of lessening pain. 

" The disagreeable side effects," of which Mayer 
had so few to relate, he considers " against the 
method's unreserved recommendation." 

He concludes his report by announcing that he has 
a new method on which he will report very soon ! 

In spite of Mayer's final opinion, one cannot but 



THE REMARKABLE REPORTS OF 1908 201 

feel that his small record must be placed on the credit 
side of the scopolamin-morphin annals. 

MANSFELD 7 

O. Mansfeld, of Budapest, studied the use of 
scopolamin at the Freiburg Frauenklinik, and it is 
pleasant to remember that the Dammerschlaf is to- 
day permanently established in the Budapest hos- 
pital. 

Mansfeld feels that one cannot gain a clear idea 
of the technic of this method from Gauss's publica- 
tions; personal study is necessary. 

He gives a very clear and detailed account of his 
manner of dosage, which I will reproduce in the 
hope that it may be helpful to other experimenters. 

" First injection: .00045 8- scopolamin + .01 g. 
morphin if spontaneous process of birth is to be ex- 
pected and vigorous labor occurs every five minutes. 
Second injection: .0003 g. scopolamin one hour 
later, using the memory test after a half hour. If, 
after a further thirty to sixty minutes, no amnesia 
has occurred, a third injection is to be given one and 
a half hours after second injection. The narcotiz- 
ing effect of second injection will not take place for 

7 From article published in the Vienna Clinical Weekly, No. 
1, 1908, pages 17-19. 



202 THE TRUTH ABOUT TWILIGHT SLEEP 

a half hour and therefore cannot be noticed before 
one hour has passed; the memory test used before 
the third injection gives information as to the pa- 
tient's condition a half hour previous." 

He especially draws attention to the fact that 
Gauss does not wish to attain painlessness and am- 
nesia but only amnesia. Actual painlessness is only 
obtained by overdosing and must therefore be re- 
garded as dangerous. 

" Conducting a Dammerschlaf is very difficult and 
requires care and constant control, and can therefore 
only be carried out in special wards." 

He found the birth process to be protracted by the 
use of scopolamin-morphin, because of its decreas- 
ing the abdominal action, " but without, however, 
necessitating any operative interference. 

" The actual value of the method consists in at- 
taining amnesia. The practical value consists in the 
promise which can be given anxious patients that 
they will remember nothing whatever about the birth 
afterward." 

matwjejew 8 

The succinct account of Dr. G. T. Matwje Jew's 
experiments in Moscow makes one wish to know 
more of this cheerful Russian gentleman. 

8 From Zentralblatt, 1908. 



THE REMARKABLE REPORTS OF 1908 203 

His results were altogether delightful. 

Dr. Matwjejew insists that " scopolamin does not 
prolong birth; on the contrary, it often stimulates 
the pains of labor. 

" The suffering of the mother decreases, often 
disappearing altogether. No kind of side effects 
were ever observed." 

He disposes of the question of oligopnea without 
waste of words : " Children often born asleep, but 
pulse and respiration normal. They wake up after 
a while spontaneously." 

Dr. Matwjejew goes into no details as to his 
technic or dosage, but his results are eloquent of sat- 
isfaction and conscientious method. 

I have in this chapter given condensations of all 
the reports contained in the German medical jour- 
nals for the year 1908. One cannot but feel that 
during this year the cause of scopolamin-morphin 
strode forward with three-league boots. 

The mothers owe a vast debt of gratitude to Hoch- 
eisen, for his report undoubtedly caused all careless- 
ness of technic to be eliminated from the experi- 
ments which followed in other hospitals. 

Even Steffen's honest failure had its beneficial 
effect, for it caused doctors to realize the importance 
of going to Freiburg for a careful study of the 



204 THE TRUTH ABOUT TWILIGHT SLEEP 

method, before undertaking experiments of their 
own. 

But for the mistakes of 1907, we should not have 
had the successes of 1908. 

The most interesting and convincing thing about 
the reports of this year is that two of these records 
came from the hospitals of Stuttgart and Budapest, 
where now, after six years, the Twilight Sleep is still 
a treasured institution. 



XI 



The Singular Metamorphosis of Scopolamin 
in Surgery 

I AM sure that all those unfortunates who have 
had surgical operations retain in the memory 
the following especially dreadful impressions of the 
beginning and the end; the horror of the placing of 
the cone over the face, the sense of suffocation com- 
bined with the mental distress of the early stage of 
an inhalation narcosis, then the coming-to after the 
operation, the extreme pain which so often has to be 
lessened by morphin, the wretched nausea which fre- 
quently results in racking vomiting. 

If these features could be eliminated I believe 
many of us would face the operating table with far 
more courage; that they can be avoided is proven 
by the following reports, and scopolamin is again 
the magic. 

It is a most singular thing to find here the same 
loudly denounced " poison " used in operations in 
the same manner and the same combination in which 
it is employed in childbirth, and now find only its 

205 



206 THE TRUTH ABOUT TWILIGHT SLEEP 

praises being sung as a " most humane and valuable 
drug." 

We prepare ourselves to hear all the old familiar 
list of " side effects " — red face, increase of pulse, 
deleterious effect upon the heart and respiration, and 
vomiting of patient, but instead we suddenly find all 
these concomitant effects of scopolamin vanishing 
from the scene. We ask ourselves: is it possible 
that this is the same evil chemical of which we have 
heard so much abuse — this benign drug which we 
now find recommended over and over as a prevent- 
ive of vomiting? 

The question arises in our minds and will not be 
laid : " Why is scopolamin such a poison when used 
for the relief of women in childbirth and such a 
harmless and beneficent drug when employed in sur- 
gical operations ? " 

The inconsistency must strike the most thought- 
less among us. 

We who are begging for the adoption of Twilight 
Sleep for ourselves and all our sister women in child- 
birth, must arm ourselves with positive knowledge 
on the subject of this drug on which all our hope of 
relief depends. 

That is the reason I have spent months in collect- 
ing for you all the information to be gotten on the 
use of scopolamin — information which you might 



METAMORPHOSIS OF SCOPOLAMIN 207 

not be able to find yourselves, for I know that not 
one mother in a thousand ever has an opportunity of 
seeing a medical journal, and even if she has she is 
generally too busy a person to spend time informing 
herself on questions which she believes belong only 
to the field of her family doctor. 

You may think I am putting you to unnecessary 
trouble when I place before you the records of scopo- 
lamin in surgery and beg you to read them with the 
greatest care, but my reason is this : I want to prove 
to you that scopolamin is not the dangerous drug 
which some of the physicians have recently been de- 
claring it to be — nowhere is that fact so proven as 
in the history of its use in surgical operations. 

It seems especially appropriate to touch on this 
phase of the subject here, as many of the reports of 
1909 deal with the use of scopolamin in mixed nar- 
cosis for gynecological and other operations. 

In this chapter I shall gather together the impor- 
tant European reports of the year extending from 
1908. 

We first find Dr. Boesch * declaring : " We agree 
with Dr. Kronig that scopolamin is one of the most 
humane and valuable drugs." 

^'The Value of Scopolamin-morphin in Gynecology," by 
Dr. Eugen Boesch. No. 4, Zentralblatt. 1908. 



208 THE TRUTH ABOUT TWILIGHT SLEEP 

Dr. Boesch is the assistant at the Woman's Hos- 
pital of Basel. 

He continues : " The experience of our hospital 
has made us fast friends of scopolamin-morphin. 

" Aside from our use of it in birth, scopolamin- 
morphin has been employed in 2,000 operations in 
our clinic without any bad symptoms being evidenced 
by the patients. 

" Before every narcosis — chloroform-ether-oxy- 
gen — scopolamin-morphin has been given on prin- 
ciple ever since 1905. 

" For the past two years we have also used it alone 
in minor operations, such as enlargements, incisions, 
and operations under local anesthesia. 

" For one year on the eve of all large operations 
our patients receive first one gram of veronal which 
causes them to fall into deep invigorating sleep, then 
with the effects of veronal the later administered 
manner, causing the narcosis to take better ef- 
fect. 

" One hour before the operation we give a hypo- 
dermic injection of .0005 g. scopolamin -f- .015 g. 
morphin and induce an immediate strong desire to 
sleep, thus lessening the excitability of the reflexes. 

" It is always possible to merge a scopolamin- 
morphin Dammerschlaf without interruption, by 



METAMORPHOSIS OF SCOPOLAMIN 209 

chloroform-ether-oxygen, to the stage of deep nar- 
cosis. 

" After the scopolamin-morphin injection the pa- 
tients sleep quietly, agitation is spared, and they do 
not realize when the anesthetic is administered, the 
general narcosis creeping gradually upon them. 
With this method we need to employ much less 
chloroform and ether, which is a very important 
point. 

" The Dammerschlaf lasts long, extending over a 
period after the operation. When the patient 
awakens the first pain of the wound is much less than 
under ordinary narcosis; they also vomit rarely, 
but should there be any vomiting it is without effort 
and evil effect." 

There are two very interesting reports from 
France. 

Leon Durand 2 finds scopolamin of the greatest 
benefit in infantile surgery. 

" It here has the same advantage it shows in oper- 
ations upon patients of mature age, viz. : suppression 
of the fear of operation, diminishing of the danger 
of syncope, reducing the necessary chloroform to 
very small quantities, inducing quietude, etc." — now 
read with especial attention — " there is no vomiting, 

2 Zentralblatt, 1908. 



2io THE TRUTH ABOUT TWILIGHT SLEEP 

no dilatation of the pupils, no contraction of the 
abdomen, and lessened loss of blood." 

These last sentences would seem to explode sev- 
eral well-established prejudices. 

As for his dose, Durand gives it as 1.2 mg. scopo- 
lamin -f- 1.2 eg. morphin. 

" The most favorable moment for operating is 
from one to one and a half hours after the injec- 



Louis Dumont 3 finds that scopolamin injections 
render anesthetizing more easy and " insures absence 
of complications and vomiting." 

The results of this mixed narcosis he found " far 
superior to those obtained by use of chloroform or 
ether alone, or in combination with chlorethyl. 

" The usual agitation preceding chloroform is sup- 
pressed by scopolamin; it also prevents syncope at 
the beginning of narcosis." 

One of the greatest advantages he states to be 
" painlessness after the operation ; morphin rarely 
has to then be used. 

" They sleep for five or six hours after operation 
and then awake without showing the toxical dysp- 
nea " (difficult breathing) ; " of chloroformized pa- 
tients. 
s Zentralblatt, 1908. 



METAMORPHOSIS OF SCOPOLAMIN 211 

"Vomiting during operation never occurs; if it 
happens afterward it is neither violent nor long last- 
ing. 

" In over 300 scopolamin-morphin mixed narcoses 
only 43 per cent, even showed nausea. 

" Artificial emptying of the bladder after opera- 
tion was never necessary. No albumen was ever 
shown to be present in the urine. The quantity of 
urine was always above normal. 

" Even after heavy operations patients may be 
given liquid nourishment on the fourth or fifth day, 
whereas after use of chloroform alone, it is gener- 
ally necessary, in like cases, to wait until the eighth 
day, for fear of vomiting. 

" In cases of debility or aged patients, the scopo- 
lamin is by far preferable. In all our cases of scopo- 
lamin-morphin narcosis there have been no deaths." 

Dr. G. Blisniansky, 4 assistant at the Royal Uni- 
versity Frauenklinik of Tubingen in Wurtenburg, 
reports on thirty-two cases in which she employed 
scopolamin-morphin on patients ranging in age from 
twenty-five to fifty-two years. 

One case was complicated by extreme anemia, 
three had heart disease, three tuberculous affection 

*Zentralbt. f. Gynak. Liepzig. 1909. XXXIII, pages 301- 
306. 



212 THE TRUTH ABOUT TWILIGHT SLEEP 

of the lungs, and there were two patients with pro- 
nounced hysteria. These patients only required 
minor operations. 

" At from one-half to one hour before operation 
we injected separate solutions of 3 dmg. scopolamin 
+ 1 eg. morphin. In three- fourths of our cases 
we obtained hypalgesia, in the remainder amnesia. 
When in rare cases the temperature rose, it was not 
the fault of scopolamin, as it was afterward found 
to denote the beginning of a complication. 

" No influence by scopolamin upon the pulse takes 
place." 

The most amazing statement made by Dr. Blisni- 
ansky is that nearly all patients got up within twenty- 
four hours after operations. 

From British doctors we have equally good re- 
ports. 

Leedham Greene 5 says the advantage of scopo- 
lamin-morphin injections before inducing general 
narcosis are: 

" Much less chloroform and ether will then be 
required. 

" Patients sleep quietly for several hours after 
operation. 

5 At the Seventy-seventh Annual Meeting of the British 
Med. Asso., Belfast, 1909. Brit. Med. Jour., 1909, II. 



METAMORPHOSIS OF SCOPOLAMIN 213 

" Scarcely any vomiting after operation. 

" The method is less risky than narcosis without 
scopolamin-morphin, and superior to analgesia of 
the spine." 

H. Torrance Thompson and Dennis Cotterill 6 
find the advantages of this method to be : 

1. As patients are calmed and have no fear, shock 
is avoided during operation. 

2. Because of the action of scopolamin upon the 
salivary glands there is a beneficial lessening of the 
secretion of saliva during narcosis. 

3. The quantity of chloroform or ether necessary 
to induce narcosis is very small. 

4. Vomiting during or after operation becomes 
rare and is never serious. 

5. After operation the patient usually enjoys a 
good sleep. 

P. Sick, 7 of Leipsic, points out that aside from 
eliminating the danger of having to use large quanti- 
ties of chloroform, scopolamin-morphin " secures an 
unlimited field of usefulness to ether which can be 
reduced to one-third its usual quantity ; thus we need 

6 Edinburgh Med. Journal, Dec. 1909, n. s. Ill, pages 548- 

554- 

7 German Med. Weekly, 1910. 



214 THE TRUTH ABOUT TWILIGHT SLEEP 

not fear the usual irritating effect of ether upon the 
lungs. 

" The amount of scopolamin may be increased — 
adapting the dose to individual and case — without 
danger, but the morphin should be limited to its 
smallest effective quantity and should only be given 
with the last injection of scopolamin half an hour 
before the operation, in quantity of .01 g. 

"If the doses are properly proportioned this com- 
bined narcosis takes first place among all methods, 
not only on account of its harmlessness and its scope 
of action but also on account of the humane manner 
in which it takes effect. 

" When given in proper proportions and combina- 
tions, these several chemically different narcotics act- 
ing upon different systems of the organism permit 
narcosis to be obtained with the lowest individual 
doses and for that reason the least danger is incurred 
both during and after operation.' , 

Edv. A. Bjorkenheim, 8 of Helsingfors, Finland, 
finds when using scopolamin-morphin before chloro- 
form in gynecological operations that " the course of 
narcosis is quiet and undisturbed, the sleep begins 
calmly and the patient displays no agitation. Dur- 

8 Zentralblatt, 191 1, 



METAMORPHOSIS OF SCOPOLAMIN 215 

ing narcosis there is never vomiting and if there is 
any after operation it is only slight." 

Dr. Gauss in the 191 1 Address at Carlsruhe, 9 
in speaking of the use of scopolamin-morphin in 
surgery, says : " Since ether was introduced for 
narcosis by Jackson and Morton in 1864-7, an ^ chlo- 
roform by Simpson, the medical body, while con- 
ducting a never-ending controversy as to which of 
these drugs is better, have nevertheless agreed upon 
one point — that is, that in both methods death and 
undesirable accessory effects occur which cannot al- 
ways be avoided. 

" This fact was the basis of the endeavor to re- 
duce the danger of general narcosis by preliminary 
injections of scopolamin and morphin. The specific 
action of scopolamin-morphin as a narcotic was first 
recognized and tested by Schneiderlin and Korff in 
Freiburg in 1900. They started from the idea that 
a combination of the two alkaloids must be a par- 
ticularly happy one, as anesthetic and hypnotic ef- 
fects are common to both, while their remaining 
properties are almost without exception antagonistic. 

" It was consequently to be expected that a sum- 
mation of the desired narcotic action would be ac- 

9 At conference of German naturalists and doctors. 



2i6 THE TRUTH ABOUT TWILIGHT SLEEP 

companied by a simultaneous diminution of their 
danger. 

" As a matter of fact, recent laboratory researches 
have made it appear that in scopolamin-morphin we 
have not, as was formerly believed, two independent 
substances acting in conjunction, but a new combina- 
tion that acts in a completely different way from its 
individual components. 

" In addition to the improvement of the narcotic 
action by this combination, a number of additional 
advantages are to be observed ; these are, reduction 
of secretion of saliva, diminution of nausea, and the 
abolition of the subjective unpleasantness which ac- 
companies the initial stages of every inhalation nar- 
cosis — terror and suffocation. 

" Used as a preparatory action to an inhalation 
narcosis, surgeons soon found a new application for 
scopolamin-morphin. 

" All authors reporting on these experiments 
unanimously remark that in addition to the advan- 
tages of making a humane narcosis possible, one fact 
was striking — a reduction in the amount of inhala- 
tion narcotic used. 

" This reduction in the necessary ether or chlo- 
roform must simultaneously cause a reduction in the 
risk." 

It will be interesting to give the results which I 



METAMORPHOSIS OF SCOPOLAMIN 217 

have gathered from an investigation of statistics for 
deaths under anesthesia in major operations. 

Chloroform 1 in 2060 cases. 

Ether 1 in 5930 cases. 

Scopolamin 1 in 4762 cases: 

The ether statistics should be corrected by statis- 
tics for deaths in ether pneumonia, for these statis- 
tics only deal with deaths during operations. By 
adding the ether-pneumonia deaths, the ether death- 
rate would be greatly increased. This would prob- 
ably then give scopolamin the lowest death-rate. 

I now want to introduce this remarkable scopo- 
lamin to you in still another guise — as the savior of 
patients with the morphin habit. 

This report of Fromme's 10 is a particularly inter- 
esting contribution to scopolamine good character, 
for it goes far to prove the harmlessness of repeated 
injections, a fact which Gauss has already claimed. 
Both Gauss and Fromme believe scopolamin to have 
no degenerating effect upon the organism. 

In proving his faith in the safety of a prolonged 
scopolamin narcosis, Fromme out-does all the ob- 
stetricians and surgeons; he actually keeps his pa- 
tients under the influence of scopolamin for eight 
days! 

10 " Curing the Morphin Habit by Scopolamin," by Arnold 
Fromme. Berlin Klin. Wochenschrift, 1912. 



218 THE TRUTH ABOUT TWILIGHT SLEEP 

By this method the morphin habit can be cured 
without the usual accompanying tortures of ab- 
stinence. 

He first gives from 2 mg. up to ij^ eg. scopo- 
lamin through the mouth, gradually afterward re- 
ducing the dose to a minimum. At the same time 
he gives morphin in combination with stimulants of 
the nerves and stomach. 

While withdrawing the morphin he keeps the pa- 
tient in a narcotized condition by injections of 
scopolamin given every four or five hours. 

The scopolamin then acts in combination with the 
morphin still stored in the tissues of the patient. 
When all morphin has eventually been entirely ex- 
creted and the symptoms of abstinence have disap- 
peared, then scopolamin is discontinued without any 
evil effects. 

The narcosis is never so deep that the patient neg- 
lects to attend to his bodily functions. 

In reviewing these accounts of the use of scopo- 
lamin in surgery, the strongest impressions left are : 

1. The patient is spared agitation and distress be- 
forehand. 

2. Painlessness after operation. 

3. Avoidance of shock from operation. 

4. The " lessened danger " of narcosis. 

5. The diminished tendency to vomiting. 11 



METAMORPHOSIS OF SCOPOLAMIN 219 

The first three are also characteristics claimed by 
Gauss for his Dammerschlaf, and attested to by 
every mother with whom I have spoken. 

The last two points are interesting as being in di- 
rect opposition to the accounts of the effect of scopo- 
lamin in childbirth given by the opposers of the 
Gauss method. 

Keep in mind this important fact, of which Gauss 
has reminded us, that the surgical dose is often 
.0036 g. scopolamin + .03 g. morphin, administered 
within three hours, and then recall the small fraction 
of this dose spread over a much longer period em- 
ployed in childbirth — the significance of these surg- 
ical reports on the harmlessness and advantages of 
scopolamin then gain all the greater weight. 

" Away with this incalculable, useless and danger- 
ous poison! " exclaims Elek Ararffy 12 of Budapest, 
when scopolamin is employed in childbirth. 

" Scopolamin is one of the most humane and valu- 
able drugs," says Eugen Boesch when scopolamin is 
employed in surgery. 

Is scopolamin, then, the Dr. Jekyll and Mr. Hyde 
of medicine? 

11 Weingarten in his Inaugural Dissertation ( 1904) in re- 
porting on his experiments with scopolamin in childbirth at 
Geissen declares: "Injections never caused vomiting; on the 
contrary, they stop vomiting." 

12 Gynecological Review, 1909. 



XII 
How Does Twilight Sleep Affect the Child? 

THE first question every mother asked when the 
scopolamin-morphin method has been men- 
tioned is : " But is it safe for the baby? " 

This has conclusively proven to me that no mother 
thinks first of her own comfort. 

A woman may be a coward where pain is con- 
cerned, she may be selfish in daily life, but when it 
comes to the supreme test of relief of suffering at 
birth she will accept no method of painlessness if 
she believes it involves injury to her child. 

Dr. Max Salzberger, of Kulm, has endeavored to 
answer this question by assembling much material 
gathered from various statistical sources on the sub- 
ject. 

To Dr. Salzberger' s paper * I shall add the addi- 
tional evidence of many other physician's opinions 
on this most important phase of the Dammerschlaf. 

Dr. Salzberger begins by saying, " Now a suf- 

1 "On Danger to Child from Scopolamin-morphin," pub- 
lished in 1910 (Breslau). 

220 



HOW DOES IT AFFECT THE CHILD? 221 

ficiently large number of patients have been observed 
by obstetricians to prove positively that Twilight 
Sleep when properly conducted is without danger to 
the mother, so there only now remains to deal with 
the statements of antagonists in regard to the inju- 
rious effects of scopolamin upon the child. Ac- 
cording to these opponents the mortality of children 
during and after birth is increased. Further in- 
jurious effects are claimed to be caused by decrease 
of the milk secretion of mothers, and still further- 
more the unfavorably influenced later development 
of the child.' , 

Before beginning to prove by practical investiga- 
tion the harmlessness of scopolamin in relation to 
the child, Salzberger feels he must first put the ques- 
tion, whether is it theoretically possible to ascertain 
any influence upon the child by scopolamin adminis- 
tered to the mother ? 

Holzbach's researches have proven the amount of 
scopolamin transmitted to the child to be trifling, 
and these physiological tests have, moreover, proven 
the drug to be excreted by the child's kidneys within 
fifteen minutes after birth. 

Salzberger lays great stress on the necessity for 
severely separating asphyxia from oligopnea, as 
asphyxia must be ascribed to other causes than 
scopolamin. " This positive division between oli- 



222 THE TRUTH ABOUT TWILIGHT SLEEP 

gopnea and apnea on the one hand and asphyxia on 
the other, is not made by all writers, and thereby 
comparative statistics of the effect of scopolamin on 
the child are rendered very difficult. 

" This division is urgently necessary, because 
while the quickly excreted scopolamin may be harm- 
less, asphyxia is always dangerous and threatening 
to the life of the child. 

" Only when the mother has received an overdose 
of scopolamin can the apneic condition of the child 
be alarming. In that case even the rapid excretion 
of scopolamin may not prevent the serious intoxica- 
tion of the child. The necessity for physicians to 
adhere faithfully to the Gauss system of dosage is 
therefore all the greater, and it is especially impera- 
tive that they adhere to the memory test, especially 
as there is as yet no other reliable indication for the 
guidance of the doctor in calculating the proper 
doses. 

" As an overdosing of the mother can always be 
avoided by proper care, we need not consider this 
question. 

"If the child is born within two hours of the last 
injection of mother, it is sometimes born oligopneic; 
if it is born later it is in most cases lively, even al- 
though it has received neither more nor less scopo- 
lamin than if it had been born earlier; this proves 



HOW DOES IT AFFECT THE CHILD? 227, 

that coincidence and accident creates a large margin 
of possibilities. 

" Only could asphyxia ever be proven to be due 
to scopolamin where it can also be proven that the 
injections caused an abnormal lengthening of the 
birth. For this, statistics would have to be kept of 
asphyxiated children born both with and without 
scopolamin injections; only by this method of pro- 
cedure could it be proven that the number of children 
born in an asphyxiated condition with scopolamin 
is superior to those born outside Dammerschlaf." 

The reports of Steinbuchel, Wartapetian, Newell, 
Weingarten, Hocheisen, and Steffen point out a 
lengthening of the period of birth, but there are more 
on the other side who declare scopolamin does not 
prolong the birth period, some even declaring that 
the birth process is accelerated, and as Salzberger 
says the variation in the doses employed by almost 
all physicians shows a new difficulty in the way of 
obtaining comparative statistics, for the various 
symptoms caused by scopolamin present entirely dif- 
ferent aspects in different doses. 

" Puschnig states that he has never observed any 
such great intoxication of the child as has been ob- 
served by Hocheisen. Bass only found some chil- 
dren tired and sleepy. So we see the great difficulty 
in arriving at any positive opinion on how far even 



224 THE TRUTH ABOUT TWILIGHT SLEEP 

prolongation of birth is responsible for the condition 
of the child. 

" The statistics compiled from scientific literature 
give us the total percentage of still-born children as 
1.3 per cent. Of these still-born infants only one 
can be ascribed to scopolamin, that is the case 
described by Hocheisen : ' Fifteen minutes after in- 
jection the heart sounds of the child varied and 
finally stopped/ 

" Among 2130 scopolamin cases only 1.1 per cent, 
died up to the third day after birth. Two of these 
were ascribed by the writers to scopolamin. One of 
these children dying suddenly from heart collapse 
was reported by Bass, the other is mentioned by 
Gminder as dying from asphyxiation caused by the 
narcosis, the reflex movements were lacking and 
death occurred within a few hours. This latter was 
a very protracted birth and it is difficult for Gminder 
to prove that scopolamin was even indirectly the 
cause of death. 

" If we assume in these two cases intoxication by 
scopolamin — which, by the way, is not at all defi- 
nitely proven — it is seen from this part of our sta- 
tistics that, even counting these two deaths, 
scopolamin does not unfavorably influence the per 
cent, in the total mortality of children. 

" In 2081 cases the number of both oligopnea and 



HOW DOES IT AFFECT THE CHILD? 225 

asphyxia is found to be 23.9 per cent, and the data 
on which these statistics are based is not uniform. 
The older statements as to the action of scopolamin 
upon the child deal only with the first groping ex- 
periments made under this narcosis — experiments 
of the most varied and unfavorable character. 
With the introduction of exact instructions as to the 
dose by Gauss, the failures in Dammerschlaf be- 
came rarer and the reports subsequently more uni- 
form and therefore more easily to be compared with 
one another. 

" Even in the same hospitals statistics were 
quickly altered in favor of the method. In one 
clinic, for example, among the first series of births 
the per cent, of oligopneic children was 23.5 per 
cent, in the last series of 120 children only 7 were 
oligopnea." 

The Gauss statistics Salzberger regards as prov- 
ing conclusively that scopolamin does not affect the 
milk supply. This is the more remarkable when we 
remember that scopolamin is closely related to atro- 
pin. 

Kuenzer's statistics also coincide with those of 
Gauss. In 223 cases, which Dr. Kuenzer treated 
with scopolamin, 77.1 per cent, were able to suckle 
their children; in 121 confined without injections 
only 66.9 per cent, had milk. Preller and Lehmann 



226 THE TRUTH ABOUT TWILIGHT SLEEP 

both testify that there is no disarrangement of the 
lactation. 

" This surprising effect of scopolamin upon the 
increase of mother's milk," says Salzberger, "may 
be explained by the fact that the condition of the 
mother after a Dammerschlaf birth is so much bet- 
ter ; she is able to get up sooner and this alone would 
exercise a very stimulating effect upon the lactation. 
That there is a stimulation of the milk secretion by 
scopolamin has been pointed out by both Kuenzer 
and Jusgen. Among Kuenzer's 223 scopolamin pa- 
tients, 47.5 per cent, got up before the third day. 
Only Hocheisen and Bass have observed that the 
children nursed indifferently, showing a disposition 
to fall asleep before being satisfied, during the first 
few days. This prolonged toxical effect has never 
been observed by other writers. Even without 
scopolamin, mothers often state that their infants 
are drowsy generally and fall asleep before they 
finish suckling. 

" Other writers cannot conform Hocheisen's sus- 
picion that the drug will have an injurious effect 
upon the child's later mental and bodily development. 
Gminder found no evidence of disturbance during 
the ten days the children remained at the hospital. 
Puschnig also declares there is no effect on the first 
stages of development. 



HOW DOES IT AFFECT THE CHILD? 227 

" Among 500 scopolamin children born between 
1905 and 1907 I have made inquiries among the 
mothers and received 318 answers which show that 
only seven children (1.4 per cent.) died during the 
first nine days. Of these 318 children 285 (89.7 
per cent.) were still living after one year. One 
hundred and two had not yet reached a year's age 
and of those ninety-two were still alive. These 
figures prove that scopolamin administered to the 
mother has no injurious effect on the health of the 
child during the first year." 

Salzberger even investigated the respective doses 
given the mothers in those cases where the children 
died within the first year and found the injections 
averaged .00126 g. scopolamin. The mothers of 
children still living after one year had received 
more scopolamin — at an average .00131 g. 
Therefore scopolamin cannot be accused. Further- 
more, there were no symptoms shown by the chil- 
dren who died which could point to toxic effect of 
the drugs. 

" A resume of these observations and statistics 
give the result that scopolamin when properly ad- 
ministered harbors no danger to the health and de- 
velopment of the child. " 

Salzberger 's very fair and judicial paper only 
proves to my mind that as yet nothing has been 



228 THE TRUTH ABOUT TWILIGHT SLEEP 

positively proven one way or the other on this sub- 
ject, although the preponderance of evidence is in 
favor of scopolamin. 

Final proof must be lacking until statistics are 
very differently compiled. 

First: separate statistics of asphyxia on the one 
hand, and oligopnea on the other, must be provided. 
Second: statistics should be kept of the results of 
various physicians employing the same dose, as it 
has been shown that dosage has everything to do 
with the effect on the mother as well as on the child. 

Until such uniform data are forthcoming we have 
only the personal opinions of doctors based on their 
individual experiments variously conducted, on 
which to depend. 

As, however, the consensus of personal opinion, 
even under such varying technic, is to the credit of 
scopolamin and even the unsatisfactory statistics 
agree with these opinions, it would certainly seem 
safe to say that as yet it is entirely unproved that 
scopolamin is injurious to the child. 

Here are the opinions of many doctors. 

Bruno Bosse of Berlin : 

" This method does not cause mental stunting of 
the children," 

J. Fonyo of Budapest: 



HOW DOES IT AFFECT THE CHILD? 229 

" For the child scopolamin is not dangerous if 
correct technic is observed." 

Josue A. Beruti of Buenos Aires : 

" There is no injury to the child's organism from 
scopolamin." 

J. R. Freeland (University of Pennsylvania, 
L. M.) and Bethel A. H. Solomons, M.B. (Uni- 
versity of Dublin, L. M.) in a joint paper conclude: 

" No ill effects to mother or child need be ex- 
pected to follow the rational administration of sco- 
polamin." 

Dietschy of Bale : 

" Children take the breast after scopolamin like 
any others." 

Mayer of Marburg : 

" No subsequent effect upon the child was ob- 
served." 

F. N. Iljin of Petrograd: 

" All mothers and children left the clinic abso- 
lutely sound." 

Preller of Mannheim : 

"If children are left alone they will sleep off 
intoxication. No lasting injuries to children were 
observed and they develop well." 

Pisarewsky (Polish Monthly Journal for Gyne- 
cology and Obstetrics, 1905) : 



230 THE TRUTH ABOUT TWILIGHT SLEEP 

" Children are born fresh and lively." 

VonHerff of Bale: 

" Children never exhibited serious symptoms 
after scopolamin." 

Cremer (Medical Quarterly Review, 1908) : 

" Children are never asphyxiated by scopolamin." 

W. A. Brodski of Moscow : 

" If correctly administered scopolamin is entirely 
harmless to mother and child." 

R. C. Buist of Dundee : 

" The description of the attitude and behavior of 
the infant with its readiness to sleep and super- 
ficial respiration does not suggest any marked de- 
parture from the normal." 

Kleinertz of Stuttgart: 

" Most of the children were vigorous and hearty. 
No child died as a consequence of the injections. 
Neither was any deleterious effect on the later de- 
velopment of children observed." 

Frigyesi of Budapest: 

" The injections never caused the death of a 
single child. Accurate investigations were made on 
the reduction of milk, the amount of food taken 
by the children, and their weight. These investi- 
gations brought to light nothing to the disadvantage 
of the method." 

At a meeting of the British Medical Association 



HOW DOES IT AFFECT THE CHILD? 231 

held at Sheffield in 1908, Dr. Bernhardt Kronig 2 
explained the strikingly small mortality of children 
both before and after birth in Twilight Sleep as 
being due to the fact " that the moderate inactivity 
which is produced in the respiratory center during 
birth, by very small quantities of scopolamin, is of 
advantage to the child; the child is made a bit 
drowsy and this drowsiness prevents it from pre- 
mature intra-uterine " (before birth) " respiration. 
The air passages remain free and in cases of slight 
asphyxia, for example, prompter and more certain 
revival is to be expected." 

2 British Med. Journal 1908, Vol. II. 



XIII 

Reports from Hungary, The Argentine, 
Russia, England, and Germany 

THE day of violent opposition to Twilight 
Sleep on the Continent seems to have ended 
abruptly. 

In the reports of 1909, 'io and 'n one searches 
in vain for a repetition of the picturesque fury of 
Bumm and Hocheisen or the failure of Steffen. 

The reports are, nevertheless, full of interest — 
greater interest, in fact, for they continually add 
more convincing evidence that even with the great- 
est variation in its manner of application the Dam- 
merschlaf can positively guarantee to women a sure 
and safe respite from the agony of childbirth. 

" Never before have I seen so many grateful and 
smiling faces in the lying-in wards as from and 
after the first day of the introduction of Twilight 
Sleep. Even the mere explanation of the action of 
the Dammerschlaf has a most cheering effect upon 

the mothers-to-be." 

232 



REPORTS FROM MANY COUNTRIES 233 

With these words Frigyesi 1 of the Second Buda- 
pest Woman's Hospital opens his report on 200 
cases conducted with close observance of the Gauss 
rules. 

In 80.7 per cent, of his cases complete amnesia 
was attained. In 25 per cent, there was reduction 
of pain without amnesia. 

" On the whole, no prolongation of the total time 
of birth was noticeable, in spite of the fact that in 
1 1 per cent, of cases labor became weaker. In only 
four cases was the straining action inhibited. 

" Operative frequency was 5^2 per cent, and even 
when taking the severest view of it, only 4 per cent, 
of these could be attributed to scopolamin. 

" The postnatal period was unaffected. 

" Fifteen per cent, of the children were oli- 
gopneic; none of them died. Two per cent, of 
them were born with asphyxia, but with these cases 
scopolamin certainly had nothing to do. 

" Acceleration of pulse never occurred to such a 
degree that Dammerschlaf had to be broken off. 

" I warn against the employment of scopolamin- 
morphin in private practise without sufficient ex- 
perience. 

"If the right dose is given there is no injurious 

1 Gynecological Society of Dresden, May, 1909, and Ge- 
selhch. d. Aerzte, 1908, Budapest, 1909, pages 19-22. 



234 THE TRUTH ABOUT TWILIGHT SLEEP 

effect on either mother or child, and for this reason 
I believe the Dammerschlaf to be the most valuable 
of all methods." 

High words of praise these, certainly. 

From the far Argentine comes a report on 600 
scopolamin births conducted by Dr. Josue A. Beruti 2 
of Buenos Aires. 

Dr. Beruti attained perfect success in 65 per cent, 
of his cases, partial success in 21.83 P er cent., and 
no effect in 12.16 per cent. 

" I observed no danger or injury to the mother 
or essential influence upon the process of birth. I 
furthermore declare there is no injury to the child's 
organism by scopolamin. " 

At the Eleventh Pirogow Congress of Doctors 
held at St. Petersburg (Petrograd) in 19 10, several 
Russian physicians reported on their experiences 
with Twilight Sleep. 3 

F. N. Iljin of the Imperial Obstetrical and Gyne- 
cological Institute had observed 6y cases of sco- 
polamin-morphin births. 

2 The Medical Klinic, 1909. 

3 From Central Journal for Gynecology, Leipsic, 1910, and 
the Report from the Obstetrical and Gynecological Section 
of the Eleventh Russian Congress of Doctors. 



REPORTS FROM MANY COUNTRIES 235 

Dr. Iljin carefully carried out the Gauss memory 
test and according to the results of this, gaged his 
third injection of scopolamin. 

" My first injection in case of a first child is 
given when the os is distended to about three fingers 
in width. In other cases the injection is given when 
the opening of os is two fingers and labor well 
established." 

Dr. Iljin's doses are stated to be as follows: 
First injection, .0003 g. scopolamin and .01 g. mor- 
phin, injected separately. After one hour, .00015 
g. or .0003 g. scopolamin is used without morphin. 
In thirty-eight instances he injected a total of 
.00165 g. scopolamin. 

In 60 per cent, complete amnesia was attained. 
" Many mothers knew nothing whatever of the 
birth process." 

In forty cases he observed a weakening of the 
labor. One case of delirium and four cases of hal- 
lucinations. Vomiting in three cases and thirst in 
all cases. 

No irregularity or acceleration of the pulse was 
observed. 

In one case twins were born by aid of the forceps. 
Only one case of asphyxiated child. 

He reports the afterbirth period and childbed to 
be normal. 



236 THE TRUTH ABOUT TWILIGHT SLEEP 

" All mothers and children on leaving the clinic 
were absolutely sound. 

" The use of this method necessitates experience, 
as the narcosis must be individualized to a great 
extent. 

" On the base of my observations/' says Dr. Iljin, 
" I have come to favorable conclusions : 

" Scopolamin-morphin renders birth painless." 

Dr. W. A. Brodski of Moscow conducted 200 
cases, among which were 28 women of narrow 
pelvis. 

" The narcosis had no influence upon the dura- 
tion of birth; the strength and frequence of pains 
were unaltered. 

" The duration of afterbirth period averaged only 
twenty-five minutes. 

" Only once a slight hemorrhage occurred." 

In a few cases acceleration of pulse was ob- 
served. Red face and hallucinations in 15 per cent, 
of cases. 

" There were nine cases of forceps, four of these 
being due to narrow pelvis and two to eclampsia." 

The children were all born alive. Six cases of 
asphyxia, "two because of entanglement of cord 
around the neck." 

He concludes: "If correctly administered sco- 



REPORTS FROM MANY COUNTRIES 237 

polamin-morphin is entirely harmless to mother and 
child." 

Dr. Trabscha observed in her forty cases that the 
children were very quiet after birth and cried but 
little and then weakly, until the scopolamin was 
excreted through the kidneys. This result was 
probably due to her dose of morphin which was 



Dr. Abraszanow of Poltawa after 100 cases ar- 
rives at the decision that the narcosis is uncertain, 
but his deductions are not injurious to the cause, for 
he describes this uncertainty as follows : 

" Part of the patients slept throughout " (which 
would indicate too deep a narcosis). "Some do 
not sleep but realize no pain" (indicating a proper 
Dammerschlaf). "Others feel pain but not 
strongly " — all of which indicates an uncertain 
technic on the part of Dr. Abraszanow more than 
an uncertainty in the effect of the drugs themselves. 

" The pupils are enlarged, the pulse accelerated, 
and sometimes there is vomiting." 

Dr. Abraszanow says in the end : 

" My general impression of this narcosis is favor- 
able." 

Dr. P. L. Guiseppi, M.D., F.R.C.S., Late Senior 



238 THE TRUTH ABOUT TWILIGHT SLEEP 

Medical Officer, Queen Charlotte's Lying-in Hos- 
pital, reports on thirty-seven cases, 4 twenty-six of 
which were primiparse (that is, bearing children for 
the first time) and eleven were multipara (mothers 
who had already borne other children). 

Dr. Guiseppi finds that most of his patients fall 
asleep after the labor is completed; in many cases 
the patients forget altogether the little pain they 
have suffered and when they awaken deny they 
have felt any pain whatever. 

In regard to the after effect on the child he says : 

" The child is said to be drowsy some hours after, 
but as most children sleep after birth it is rather 
difficult to know how much truth there is in this 
assertion.' ' 

As an indication that scopolamin has no influence 
upon the child's development during its first weeks 
of life, Dr. Guiseppi says: 

" As far as this investigation has gone, there has 
been no effect on the curve of the gain in weight." 

Of afterbirth hemorrhages and atony (or want 
of tone and relaxation) in the uterus, he remarks 
that, "it is very doubtful if there are any such 
risks." 

Writing of the effect on the labor, Guiseppi 
quotes Spencer Shell, who thinks labor is unaffected, 

*The Practitioner (II), July, 1911. 



REPORTS FROM MANY COUNTRIES 239 

and Newell (who is an American), who declares 
labor to be shortened definitely, while Ziffer's sta- 
tistics are as follows : labor pains normal in 7 cases, 
increased in 18, excessive in 6, and not diminished 
in any case. 

Dr. Guiseppi's conclusions in regard to Twilight 
Sleep are as follows : 

" 1. That the object of hyoscin (scopolamin)- 
morphin anesthesia is not to produce complete un- 
consciousness but to produce Twilight Sleep, from 
which the patient can be roused at any moment 
without her retaining any recollection of what has 
happened in the meantime. 

" 2. That in hyoscin-morphin anesthesia we have 
efficient means of controlling pain and one that is 
practically safe when ordinary precautions are 
taken. 

" 3. That there is danger to the child unless the 
fetal heart " (the heart of the yet unborn child) " is 
carefully auscultated" (listened for) "at frequent 
intervals. 

" 4. That the course of labor is but slightly modi- 
fied. 

" 5. That the administration and repetition of 
the injections must be gaged by the amount of suf- 
fering. (Dr. Guiseppi evidently omits the memory 
test.) 



240 THE TRUTH ABOUT TWILIGHT SLEEP 

" 6. That the morphin should never be repeated, 
but only the hyoscin. 

" 7. That the solutions for injections must be 
freshly prepared for each patient. 

" 8. That the best dose is Hoo of a grain of 
hyoscin hydrobromic -f % of a grain of morphin 
sulphate.'' 

Dr. Guiseppi regards Twilight Sleep as a reliable 
method to give relief in labor, and says the amnesia 
attained through it makes it of especial advantage 
to exhausted and very sensitive patients. 

Bruno Bosse 5 of the Berliner Klinic and Wladi- 
mir Eliasberg, in reporting on 250 cases, say: 
" Doctors must not be discouraged at first and 
should make the necessary preliminary studies. If 
in some cases there are eventual failures it is either 
due to the personal idiosyncrasy of patients to the 
drug or there has been too long a delay on the part 
of the physician in giving the first injection." 

Dr. Bosse employs the Dammerschlaf with equal 
success both in surgical operations and confine- 
ments. 

" Only absolute weakness of labor is considered 
a counter indication. High fever and hemorrhage 
would not deter us from use of scopolamine 

5 From Collection of Clinical Lectures on Gynecology, 1910, 
and Report at Berlin Med. Soc, 191 1. 



REPORTS FROM MANY COUNTRIES 241 

Dr. Bosse is the only physician to sound the fol- 
lowing warning and it may be well worth heeding: 

" A patient should not be treated with scopola- 
min-morphin on an empty stomach." 

After reading in these reports, " Memory test 
superfluous," we are not surprised to find that 
" Deep sleep was attained in 30 per cent." 

If the Dammerschlaf achieved by Drs. Bosse and 
Eliasberg was of so deep a nature it is all the more 
impressive to find them stating : 

" Abdominal action was not influenced unfavor- 
ably, there was no psychalgia (mental suffering), 
no eclampsia; the average length of birth was not 
greater, and dangerous side effects were not ob- 
served. Labor remains good as the motor func- 
tions are not affected." 

Bosse adds a personal statement to the effect: 
" I have never observed protraction of birth through 
use of this drug, although in cases of naturally pro- 
tracted births I have had to employ many injec- 
tions ; these have, however, never resulted in threat- 
ening symptoms." 

Drs. Bosse and Eliasberg give a first injection of 
3 cmg. scopolamin + 1 eg. morphin when pains are 
well established. Second injection after fifty min- 
utes. Third, half injection, is given at from two 
and a half to three hours after the second. 



242 THE TRUTH ABOUT TWILIGHT SLEEP 

" In protracted births )/t> grain scopolamin is 
given every three, four, or five hours. With prac- 
tise it will be seen that often smaller doses will be 
sufficient." 

In these 250 cases, operative interference was 
necessary in 11.4 per cent. 

There was only one case of hallucinations and 
one case of complete unconsciousness with catatonic 
rigidity of one arm. 

"Of subjective side effects," says Bosse, " I have 
observed only thirst to exist. 

" Afterbirth hemorrhage was not more frequent 
than is usual." 

Ninety-seven per cent, of the children were born 
alive. Of these nineteen were slightly oligopneic. 
Eight children were born asphyxiated, but " efforts 
at restoring life were in all cases successful." 

Both these physicians agree that " scopolamin 
does not cause mental stunting of the child," and 
Dr. Bosse ends by saying: 

" I conscientiously recommend the use of the 
Dammerschlaf in obstetrical practise." 

One of the most exhaustive papers written on the 
Dammerschlaf is that of Wilhelm Tichauer. 6 

6 " Scopolamin-morphin in Obstetric Practise." Inaugural- 
Dissertation (Breslau), 191 1. 



REPORTS FROM MANY COUNTRIES 243 

Tichauer reviews, with comments, all the obstet- 
rical reports obtainable on the subject; as all those 
reports are given in this book it is not worth while 
to quote this part of his dissertation; I shall only 
give his resume. 

" We must clearly distinguish between the two 
methods. 

u One, that introduced by von Steinbuchel, en- 
deavors to attain reduction or total abolition of 
suffering. As adherents of this method, we must 
consider all those who simply continue the injec- 
tions until pain is either reduced or done away with. 
In doing so we must, to be sure, admit that many 
of them far exceed the dose administered by von 
Steinbuchel. 

" The other method, which aims at alleviation of 
pain and amnesia, is the Twilight Sleep procedure 
described by Gauss, the principal characteristic of 
which is the testing of the powers of apperception. 

" The records show that both methods attain their 
object. Only few persons are entirely unaffected 
by the injection. A large proportion of the nega- 
tive results are due to the fact that the birth took 
place before the scopolamin-morphin had time to 
exert its action. 

" The object is attained in the great majority of 
cases — so much is admitted even by opponents — 



244 THE TRUTH ABOUT TWILIGHT SLEER 

and is consequently beyond question. The only 
further question is what price is paid for it. 

" Flushed face, headache, intense perspiration, 
are symptoms that need hardly be taken into account 
in comparison with the great alleviation of the suf- 
fering. Nausea also occurs at confinements when 
scopolamin is not used. Surgeons, who on other 
points are so frequently quoted by opponents of the 
method, state categorically that scopolamin-morphin 
does not cause the usual annoying sickness after 
narcosis. 

" Maria Garca and Salvatore Diez of the Turin 
Lying-in Hospital even use the drug for hyper- 
emesis " (extreme vomiting) "and that with in- 
variable success. 

"Restlessness, delirium with hallucinations, and 
twitchings (even on the assumption that these 
symptoms are really concomitant effects of scopola- 
min), look much worse than they are. This is the 
universal opinion, and is shared even by opponents, 
and, in addition, such symptoms occur relatively 
seldom. To the patient they do not matter in the 
least. 

" Only a few observers attribute to the drug an 
action on the heart and breathing, or the afterbirth 
period, the lactation, or the subsequent development 
of the child. Most of those who have used it deny 



REPORTS FROM MANY COUNTRIES 245 

the existence of such an action, provided that cor- 
rect dosage is conscientiously adhered to. The 
same is the case with regard to atonic hemorrhage. 
The investigations have not proved any action of 
that kind. 

" The case of intoxication of the mother observed 
by Gminder can be laid to the charge of his pro- 
cedure. Whether the case of the death of the 
mother reported by von Bardeleben should be as- 
cribed to scopolamin is, in view of all the circum- 
stances, extremely questionable. 

" According to most of the authors, the oligopnea 
and asphyxia of the children give no grounds for 
anxiety. 

" If, in the tables, the figures for the reduction 
of the birth pains and straining action occasionally 
appear somewhat high, this is due partly to the 
procedure employed, partly to the very severe stand- 
ards of individual authors, and partly also to 
accompanying circumstances. Under the headings, 
1 deterioration of the pains/ and ' deterioration of 
the straining action,' some authors include also those 
cases which show only very slight effect. Only so 
can we explain the fact that in spite of high figures 
in these reports the duration of birth is given as 
normal or only slightly prolonged. From the re- 
sults given we are certainly entitled to say that at 



246 THE TRUTH ABOUT TWILIGHT SLEEP 

the worst the birth is only retarded to an inappre- 
ciable extent. 

" Of the six cases in which scopolamin is said to 
have caused the death of a child, three are stated 
to have been the indirect result of scopolamin. 
That scopolamin was really responsible for the 
deaths has not been proved beyond contention in 
any one of the cases. As we have seen from the 
accounts another explanation can very well be given. 

" Even if in 3,929 births, scopolamin is accused 
of being guilty of the death of only one mother and 
six children (and these cases are open to doubt), 
scopolamin cannot be proven to be such a terrible 
poison after all. 

"It must not be forgotten that in the use of new 
methods there are always failures at first, and in 
this case experimenters kept beginning again with- 
out reference to the experience already acquired, 
for the various obstetricians did not adhere to the 
rules which had been arrived at as the result of 
experience. 

"A comparison of the two methods shows at 
once that Twilight Sleep carried out in accordance 
with the rules laid down gives considerably better 
results than von Steinbiichers method; while the 
latter method was not in itself injurious, the often 
extremely arbitrary variations of it which have been 



REPORTS FROM MANY COUNTRIES 247 

employed seem, in fact, really to have led to very 
injurious results. 

" The Dammerschlaf method has not caused the 
death of a single child, and not one death of a 
mother has occurred which can be positively at- 
tributed to it. 

"If some workers believe on theoretical grounds 
that they can dispense with the testing of appercep- 
tion, a comparison of the tables will, for most 
people, be a proof of the contrary. 

" It is clearly shown by them that scopolamin- 
morphin as used in the form of Dammerschlaf, with 
precise observance of the rules laid down, is capable 
of attaining reduction of pain and amnesia without 
endangering either mother or child. 

" One point, to be sure, must be again and again 
insisted upon. The medical man must be thor- 
oughly familiar with the method and must be able 
to observe the patient continuously, not so much on 
account of the great danger of scopolamin, as be- 
cause otherwise the desired effects will not be ob- 
tained. 

" The continuous observation is a demand that 
the general practitioner can hardly fulfil, and the 
introduction of Twilight Sleep into general practise 
will probably split upon this rock. 

"There is the further difficulty in institutions 



248 THE TRUTH ABOUT TWILIGHT SLEEP 

with too large a number of patients. The presence 
of numerous patients in labor in one ward, and the 
fact that beyond this doctors and nurses are very 
much occupied, are extremely unfavorable circum- 
stances for the carrying out of the Dammerschlaf." 

August Johnen 7 of Mankarthof, in a very able 
paper covering the entire ground and history of the 
use of every narcotic and hypnotism in childbirth, 
sums up at the end by saying : 

" At any rate the scopolamin-morphin narcosis is 
the one which is to-day the best with regard to the 
lessening of suffering at birth, and it surpasses the 
semi-narcosis of chloroform and ether, on account 
of its easier and more convenient application as well 
as because of its less dangerous character/' 

7 " The History of Narcosis at Spontaneous Birth," Inau- 
gural Dissertation (Erfurt), 191 1. 



XIV 
Gauss's Latest Address on Twilight Sleep 

IN Carlsruhe in 191 1 at the Conference of Ger- 
man Naturalists and Doctors, Gauss made his 
last public address * on the Dammerschlaf, before 
turning his attention from what he considered a 
" perfect method of childbirth " to experiments 
with radium in cancer. 

" Since von Steinbuchel's first attempts in 1903 
to make scopolamin-morphin of use in obstetrics, 
between 8,000 and 10,000 births have been ob- 
served in which this combination has been employed. 
Three thousand of these births have occurred at the 
Freiburg Frauenklinik. 

" In the six years of the Dammerschlaf in our 
clinic no material change has been made in the tech- 
nic, so these 3,000 births furnish homogeneous sta- 
tistical material as a touchstone on which to test 
other groups. 

" On the basis of our six years' experience, it can 

1 " Further Experiments in Dammerschlaf," by Carl J. 
Gauss. Hitherto unpublished. 

249 



250 THE TRUTH ABOUT TWILIGHT SLEEP 

be maintained that Twilight Sleep is to be looked 
upon as devoid of danger, and a great blessing. 

" Danger to the mother never occurs if deep nar- 
cosis is avoided. The avoidance of unpleasant 
accessory effects and the obtaining of a proper and 
safe Dammerschlaf is entirely dependent on the 
strict observance of the rules given for our method. 
If an experimenter conscientiously follows these 
rules, success can be guaranteed in the majority of 
the cases ; that is, up to 82 per cent. 

" The deaths for which the method has been held 
responsible cannot be proven to be due to scopola- 
min-morphin. Under our method the mortality of 
mothers has shown no increase. 

" There is likewise no danger to the child if Frei- 
burg directions are carried out. 

" The occasionally observed oligopnea of the 
newborn is a symptom which every child brought 
to birth with the forceps also exhibits, without any- 
body attaching any importance to it. 

" Cases of asphyxia do not occur more frequently 
than in ordinary practise. 

" Retardation of the birth and increase in the 
frequency of operation need only occur if by a 
wrong technic an actual narcosis is produced. 

" The results of the various experiments of ob- 
stetricians with the method give extremely contra- 



GAUSS'S LATEST ADDRESS 251 

dictory results ; on the one hand warm advocacy, on 
the other brusk rejection. Closer examination gives 
a very simple explanation of these contradictions, 
for different methods, with technic differing in 
principle, must naturally lead to quite different re- 
sults. 

" Steinbuchel's, Hocheisen's, and our Dammer- 
schlaf are three distinctly different methods." 

It may be well to explain here that von Stein- 
biichel only endeavored to attain a reduction of 
pain without amnesia. His doses were conse- 
quently very small. The patients received from one 
to two injections of .0003 g. scopolamin +«oi g. 
morphin. In his first set of twenty cases he only 
failed to attain the desired reduction of pain in one 
case. In his second series of eleven births, all took 
place without a single failure or unfavorable inci- 
dent. 

Hocheisen's experiments, with which we are fa- 
miliar, were conducted without the memory test, 
the injections being administered entirely according 
to the complaints of the women about their suffer- 
ing — a procedure which all literature on the sub- 
ject has proven utterly unreliable. 

Gauss's method, unlike either of the foregoing, 
aimed at amnesia, or forget fulness of the birth, and 
his method was on a decidedly psychological basis, 



252 THE TRUTH ABOUT TWILIGHT SLEEP 

the dosage being regulated entirely by careful tests 
of the capacity of the patient for storing impres- 
sions after the drugs began to take effect. 

We will now resume the quotations from Gauss : 

" After the pros and cons in theory and practise 
have waged an indecisive struggle all these years, 
do not expect me on this occasion to describe the 
advantages of Twilight Sleep — our patients can 
describe them much better than we. 

" I only desire to prove here that it is the Dam- 
merschlaf itself which has refuted the bad repu- 
tation given it in some quarters. 

" I will begin with the most important point in 
the hostile criticism, viz. : the alleged dangers to the 
mother. 

" It seems to make the obstetrician's hair stand 
on end to find that childbearing patients in Twilight 
Sleep have a respiration reduced by as much as four 
breaths a minute. 

" By a confusion of Dammerschlaf with gyne- 
cological surgical narcosis (in which surgeons do 
not hesitate to employ as much as .0036 g. in three 
hours), it is then reported that the pulse increases 
in Dammerschlaf to 150 beats with a temperature 
rising to as much as 39 . 

"Obstetrical literature only records one death 
laid to the charge of scopolamin — that recorded by 



GAUSS'S LATEST ADDRESS 253 

Bardeleben. This is the case in which he says he 
administered .0003 g. It was a spontaneous birth, 
many hemorrhages, and postmortem proved anemia 
and heart trouble. 

" In accordance with the majority of authors who 
regard scopolamin as devoid of danger to the 
mother, in all our cases, the injections could not be 
regarded as the cause of a single mother's death. 

" Our maternal mortality in 3,000 cases is ten 
deaths, among which there was one with placenta 
praevia, one with colporrhexis with funnel-shaped 
pelvis ; eight patients died of puerperal fever " 
(fever following labor, due to contagion). 

" The point, second in importance, the danger to 
the child, occupies a much larger space in the litera- 
ture on this subject. 

" Twilight Sleep is said to be responsible, by 
direct poisoning, for seven dead children. 

"If we investigate these cases we find among 
them: one diaphragmal hernia " (rupture of the 
muscle separating chest from abdomen) "(Gmin- 
der), one necrosis of the roof of the skull" (dead 
bone) " due to pressure (Avarffy), one case of lues 
(Hocheisen), one double pneumonia (Avarffy), and 
one thymus death " (the thymus gland is at the 
root of the neck) "(Mayer). The cause of death 
was, in each of these cases, ascertained by post- 



254 THE TRUTH ABOUT TWILIGHT SLEEP 

mortem. Of the seven, therefore, there only re- 
mains two, one of which died after application of 
the forceps (Hocheisen), whilst the other died with 
symptoms suspiciously like those of morphin poi- 
soning (Bass). 

" Our own statistics show a child mortality of 
1.3 per cent., not including premature births, mon- 
strous births, or children already dead. We have 
never lost a single child with symptoms of scopola- 
min-morphin intoxication. 

" With regard to the children, moreover, one 
must not forget that a certain death rate will always 
remain unavoidable, and that those cases, which 
hitherto (without scopolamin) did not permit of 
the assignment of a definite cause of death, must 
not now all of a sudden be attributed to Twilight 
Sleep. 

" This is all the less justifiable, as AschofFs the- 
ory actually goes to show a reduction by use of 
scopolamin-morphin of the chances of the child 
breathing in the amniotic liquid. The following 
facts support this theory: the statistics of 1.3 per 
cent, mortality against 3.4 per cent, from 1895 to 
1904. 

"Among our children who were born alive, 80 
per cent. >were brisk and lively, 16 per cent, oli- 
gopneic, and 5 per cent, asphyxiated. 



GAUSS'S LATEST ADDRESS 255 

" I must again insist that oligopnea may be re- 
garded as entirely devoid of danger if the condition 
is not caused by too large quantities of morphin; 
the infant organism is extremely susceptible to 
morphin. 

" Holzbach's investigations have taught us that 
the child comes drunk into the world only when the 
scopolamin is injected shortly before birth into the 
mother and therefore still remains in the child's 
circulation. On the other hand, when the scopola- 
min has been dealt with, having been thrown off by 
the circulation into the child's urine, the child is 
subsequently born bright and lively. 

" What about asphyxia ? It positively never oc- 
curs as the direct result of scopolamin. 

" The frequency of asphyxia where no scopola- 
min is used is 5 per cent. 

" Salzberger's enquiries make it appear that in 
421 scopolamin children there were only 11.6 per 
cent, deaths in the first year, while the general mor- 
tality of the children of Baden for this same year 
was 16 per cent. 

" Alienists reported that they found that 4 per 
cent, of the children born with asphyxia became 
idiotic, while one-sixth of them learn to walk late 
and one-ninth of them to speak late. Henner tested 
these results on 450 children of the Breslau out- 



256 THE TRUTH ABOUT TWILIGHT SLEEP 

patient department. He found that difficult birth 
with asphyxia of the child did not dispose to ab- 
normal mental development or idiocy any more than 
normal birth. 

" It is interesting to remember here that, accord- 
ing to Mobius, through the fault of the midwife, 
Goethe was born asphyxiated. 

" Overdosing of the mother may cause injurious 
effects in the matter of birth pains, straining action, 
and postnatal hemorrhage. It is beyond all doubt 
that these deleterious effects may occur if too large 
doses are given. 

" Since an influence on the motor force of the 
uterus would make itself most clearly apparent in 
an increase in the necessity for use of the forceps 
or placental operations, I will bestow some attention 
on this point. Antagonistic literature states that 
the frequency with which the forceps are used in 
Dammerschlaf amounts to 20 per cent, and could 
easily be raised to 100 per cent. 

" The frequency of forceps cases in the Freiburg 
Frauenklinik has settled down to an average of 6 
to 7 per cent. As the subjects for all forceps ap- 
plications made for demonstration are deliberately 
sent into Dammerschlaf for this particular purpose, 
this is a figure that need not fear the light of day. 

" The frequency of manual placenta detachment 



GAUSS'S LATEST ADDRESS 257 

ranges between 2 per cent, and 6 per cent, and has 
an average of 4 per cent. This is a smaller figure 
than is to be found in most statistics. 

" We come now to the principal factor of Twi- 
light Sleep, the anesthetizing and narcotizing action 
of scopolamin-morphin. 

" I should like first to direct your attention to the 
fact that the expression ' failure ' used in the ob- 
stetrical reports is as a matter of fact not at all 
appropriate. 

" Even with the second method, which is essen- 
tially not the Dammerschlaf, a reduction of the 
suffering during birth, is, as a matter of fact, 
accomplished in every case. 

" Dammerschlaf is successful when there is an 
adequate abolition of the apperception of pain. 

" This condition is a kind of subconsciousness in 
which the cortex of the cerebrum " (outer layer of 
the big brain) " is, according to Finck, completely 
cut off from the reflex columns of the spinal cord. 

" Strassny waves aside the explanation of this 
peculiar and hitherto unknown state of conscious- 
ness with the unmannerly remark that it is a doctor- 
ing of facts to speak of ' painless birth/ and is 
inconsistent with the dignity of scientific investi- 
gation. 

" Whatever Strassny may say, our patients re- 



258 THE TRUTH ABOUT TWILIGHT SLEEP 

gard their births as ' painless ' and Twilight Sleep 
seems to us a condition well worth the trouble to 
attain, and to our patients a blessing to experi- 
ence. 

" In our first-class ward we attain perfect Dam- 
merschlaf in 82 per cent., in the second 66 per cent., 
in the third 59 per cent, and in the fourth 56 per 
cent. In 13-15 per cent, there is no effect. This 
absence of effect may be caused by too-long- 
deferred injection or personal refractoriness to 
anesthesia on the part of the patient. 

" Why does such a vast difference exist between 
the results of the Freiburg clinic and those of other 
authorities? It does not lie in any lack of sober- 
minded observation, as Herr Bumm thought fit to 
say five years ago. 

" A considerable factor in the explanation is sup- 
plied by the prejudice with which various obstetri- 
cians, on their own admission, enter upon their 
investigations. 

" Steffen, for example ( of the Dresden clinic) , 
says in his paper that he ' knows of no more pleasing 
sight than that of a strongly built woman giving 
birth to a first child with strong and painful birth 
pangs/ " 

Because of this acknowledged sentiment, one 



GAUSS'S LATEST ADDRESS 259 

writer has even gone so far as to accuse Steffen of 
being a sadist. 

" Avarffy acknowledged openly that he had re- 
course to Twilight Sleep only under compulsion. 

" Hocheisen regretted that he was compelled by 
the demand of the public to employ a poison that is 
so terrible and unreliable. With what seems a cer- 
tain malicious pleasure he records all the injurious 
effects in a series of 100 births in which there were 
134 interferences with the normal course of labor. 

" The best method in the world would break 
down when such a point of view as this is used as 
the basis for conducting an investigation as to its 
value. 

" This is especially true of Twilight Sleep which 
more than any other method requires to be employed 
with absolute sympathy and an open-minded desire 
to make the most of it. 

" It is not to be wondered at that the reports of 
Hocheisen, Avarffy, and Steffen do not precisely 
constitute a hymn of praise to the Dammerschlaf. 

" External circumstances rank only second in 
importance as obstacles to success. The lack of 
sufficient obstetrical staff is the first obstacle. 
Mansfeld is correct when he says we can form no 
idea of what enormous care, trouble, and continu- 



2 6o THE TRUTH ABOUT TWILIGHT SLEEP 

ous watching a well-conducted Dammerschlaf de- 
mands. 

" Fehling draws attention to the fact that not 
every young doctor displays capacity for carrying 
out the method. 

" I have also learned from private sources that 
in several clinics the passive resistance of the mid- 
wives has forced the physicians to relinquish the 
method. 

" The final cause of failure is that unfortunately 
in many hospitals the correct technic has not been 
employed. It may also be assumed that the assis- 
tants in these clinics, who are merely gaining ex- 
perience in the delivery room, are not given careful 
instructions about Twilight Sleep, especially the 
memory test. 

" As early as 1907 I wrote an emphatic warning, 
viz. : ' The special action and safety of the Dam- 
merschlaf are based solely upon the testing of the 
powers of memory and by this alone our method 
must stand or fall.' With regard to this passage 
Mans f eld has said : * It is really extraordinary 
that words written in such perfectly clear German 
can be so misinterpreted.' 

" Without paying any attention to this clause 
which is the foundation of my method, Hocheisen, 



GAUSS'S LATEST ADDRESS 261 

Messer, and others have come forward as opponents 
of the Dammerschlaf. 

u Twilight Sleep is a narcotic condition of ex- 
tremely limited breadth — like unto a mountain 
crest. To the left of it lie the dangers of too deep 
action, with narcosis and weakness of birth pangs; 
to the right the dangers of too shallow action with 
the retention of consciousness and sensibility to 
pain. 

" When the testing of the power of memory 
keeps the Dammerschlaf within the confines of the 
mountain crest, then we find Twilight Sleep not 
only devoid of danger but the great boon to women 
it is proved to be by the gratitude of our patients." 



XV 



How the Variability of Scopolamin was 
Overcome 

BECAUSE of the complaints made about the 
unreliability of scopolamin, Prof. Walther 
Straub, 1 of the Pharmacological Institute of the 
Freiburg University, began experiments in 1907 to 
discover the cause of this variability. 

These complaints came generally from physicians 
who used scopolamin to produce Twilight Sleep; 
exact dosage is here of great importance, as the 
obstetricians have to work with the smallest effec- 
tive quantity — .0003 g.-.ooo45 g. scopolamin. 

Very rarely were any complaints made by sur- 
geons who employed scopolamin for total narcosis, 
where four times the amount used in Twilight Sleep 
is generally employed. In the surgical dose the 
effect of decomposition would naturally be much 
less noticeable than in the small, exact injections 
required for childbirth. 

1 " About Decomposition and Conservation of Scopolamin- 
solutions, by Walther Straub. Munch. Med. Woch., 1913. 

262 



VARIABILITY OVERCOME 263 

Professor Straub did not accept the current opin- 
ion that the poisonous products resulting from the 
decomposition of this alkaloid originated in the 
scopolamin solution itself. He believed that de- 
composition was caused by a process of saponifi- 
cation. 2 

" If my supposition was correct, it should be pos- 
sible to stop this saponification by the addition of 
conserving substances. As scopolamin is applied 
hypodermically, prevention of irritation of the tis- 
sues must be assured; this caused a limited choice 
of substances which could be employed for the con- 
servation. 

" While testing various substances I found at 
last the very easily soluble alcohol mannite of six 
fold value" (sexatonic alcohol mannite) "to be 
entirely suitable for the purpose. Solutions of sco- 
polamin preserved with from 5 to 20 per cent, man- 
nite were proved to be reliable." 

Straub's first investigations in 1907 were for 
some reason not resumed until 19 12. He had then 
in his possession some stored solutions of scopola- 
min treated by mannite which were five years old; 
these were given to the Freiburg Frauenklinik for 
testing experiments. " They were used for Twi- 

2 A conversion of fat or oil into a soapy substance by the 
action of an alkali. 



264 THE TRUTH ABOUT TWILIGHT SLEEP 

light Sleep and proved to be as effective as freshly 
made solutions.'* 

Straub felt that the ever-increasing use of sco- 
polamin-morphin in semi-narcosis required that he 
lay a theoretically secure foundation for his claims 
for the preserved scopolamin; with this object in 
view he not only made biological tests but he stored 
for one year scopolamin solutions with and without 
addition of mannite in open and sealed vessels, in 
the dark and in the light. 

After one year it was found that the resistance 
of scopolamin, treated by mannite, to the light was 
considerable. When kept in open vessels in the 
full light, solutions preserved by mannite even 
though totally moldy were found to be more effective 
than seven months' old sealed solutions not pre- 
served. 

In the case of scopolamin boiled in a water bath, 
an addition of 10 per cent, mannite proved to have 
a conserving effect. 

For the biological experiments he used the heart 
of a frog. These experiments were rendered very 
difficult as the structure of the frog's heart prevents 
uniform distribution of a poison. The poison em- 
ployed by Straub was muscarin — not to be bought 
in the open market — and he eventually found it 
necessary to isolate the auricle of the frog's heart 



VARIABILITY OVERCOME 265 

for operation ; the auricle being composed of a few 
thin layers of cells was found to be particularly 
sensitive to muscarin. 

After the action of the auricle had been arrested 
by the use of poisonous muscarin, scopolamin was 
employed both in freshly made solutions and in pre- 
served state with the following results : 

The lowest concentration of a freshly made sco- 
polamin solution which produced an effect upon the 
auricle of a frog's heart, first treated with muscarin, 
was Vsq million. 

The contractions of the auricle, resulting from 
this application, regained one-eighth of their normal 
action. 

The same result was produced by .02 per cent, 
scopolamin solution which had been stored for seven 
months, but it was necessary to concentrate the 
stored scopolamin to eight times the strength of the 
freshly made solution. 

Straub considers that this proves, not that the 
preserved scopolamin has only one-eighth the 
original strength, but it shows that stored solutions 
lose in strength considerably, even though remain- 
ing perfectly preserved. 

Professor Straub then had the firm of Hoffman 
La Roche make solutions preserved by mannite in 
vials of .0003 g. scopolamin per cubic centimeter 



266 THE TRUTH ABOUT TWILIGHT SLEEP 

and these are the solutions now used by the Freiburg 
Frauenklinik. 

Wondering whether the war would make it now 
impossible for the physicians of Britain and Amer- 
ica to procure the " Scopolamin Haltbar " (pre- 
served scopolamin) of Professor Straub, I went to 
London to see the leading wholesale chemists, and 
I was delighted to discover that the factory of Hoff- 
man La Roche is situated in Switzerland and so far 
the war has in no way affected the shipping of Swiss 
chemicals to England. 

I was also assured by Parke, Davis & Co. 
that even should the war eventually shut off all 
chemical trade with the Continent, their present 
supply of scopolamin hydrobromic was sufficient to 
meet all demands ; moreover, I find that the British 
chemists are as a rule making their own scopolamin, 
independent of Continental supply. 

DR. SIEGEL'S EXPERIMENTS WITH STRAUS'S 
PRESERVED SCOPOLAMIN 3 

Dr. P. W. Siegel, assistant at Kronig's Frauen- 
klinik, was provided by Professor Straub with some 
vials of mannite-scopolamin solution which had 
been stored for from thirteen to fifteen months. 

As there was but a limited quantity of these solu- 

3 Munich Medical Weekly, 1913, No. 41. 



VARIABILITY OVERCOME 267 

tions, Dr. Siegel was only able to make a first ex- 
periment in 22 cases, but as these experiments were 
not made to prove the value of the Dammerschlaf, 
but only to discover the biological action of the pre- 
served solutions, the number of cases is sufficient 
for a test. 

In his opening remarks Siegel comments on the 
great disadvantages under which the method of 
Twilight Sleep has always struggled because of the 
unreliability of scopolamin, which even when steri- 
lized was apt to decompose. 

" As the Dammerschlaf is a state fluctuating be- 
tween waking and sleeping, an exact dosage is of 
the greatest importance, and for this perfect dosage 
a reliability of the drug is a most important factor. 
With the scopolamin solutions varying considerably 
in their effect, according to their age, correct con- 
duct of Twilight Sleep has been rendered most diffi- 
cult and complicated. Now, at last, Straub has 
prepared a lasting scopolamin by the addition of 
soluble alcohol mannite. This preserved solution, 
when used in pharmacological and biological experi- 
ments, exhibits the same qualities as those shown in 
freshly made solutions." 

To make the tests of his experiments more clearly 
observable, Dr. Siegel contrasts the results of his 
own use of preserved scopolamin-mannite with the 



268 THE TRUTH ABOUT TWILIGHT SLEEP 

statistics of 500 of Gauss's cases and 600 of Beruti's. 
We find in the specified 500 cases of Gauss the 
following figures. 

76.2 per cent. — successful Dammerschlaf. 
18.2 per cent. — reduction of suffering. 
5.6 per cent. — no effect. 

Beruti reports : 

65. per cent. — successful Dammerschlaf. 
21.83 P er cent - — reduction of suffering. 
13.6 per cent. — no effect. 

By combining the results of both Gauss and Beruti 
we get the following average : 
Gauss and Beruti: 

70.6 per cent. — successful Dammerschlaf. 
20. per cent. — reduction of suffering. 
9.5 per cent. — no effect. 

Now compare this average of results from use of 
freshly made scopolamin solutions with Siegel's re- 
sults from use of preserved scopolamin which had 
been stored for over a year. 

Siegel : 

74. per cent. — successful Dammerschlaf. 
26. per cent. — reduction of suffering. 
o. per cent. — no effect. 



VARIABILITY OVERCOME 269 

One reaches the conclusion that even after many 
months of storage, mannite-scopolamin does not 
lose its effectiveness. 

" Fresh solutions," says Siegel, " have been shown 
to produce but slight side effects, similarly, with pre- 
served scopolamin, I have observed no subjective 
side effects. With an exception of a slight prolon- 
gation of the pains there were no objective effects. 

" On the basis of my observation of several hun- 
dred Dammerschlaf births with fresh solutions of 
scopolamin, I am able to state that the side effects of 
mannite-scopolamin do not occur more frequently 
than when using fresh solutions — I have even 
formed the conclusion that they are less. The*dura* 
tion of birth was normal. 

" In the 22 cases, 22 children were born alive. 
There were 20 spontaneous births. Forceps had to 
be employed twice; (1) on account of narrow pelvis 
of mother and fluctuating heart sounds of child ; (2) 
on account of prolapsis of the cord. The latter child 
died after forty-five minutes. 

" These complications might easily have happened 
without scopolamin. 

" Fifteen children were born lively. 

" Six oligopneic. 

" One apneic " (this was the case of prolapsis of 
cord when the forceps had to be used). 



270 THE TRUTH ABOUT TWILIGHT SLEEP 

" I wish emphatically to point out here once more 
that the condition of oligopnea is absolutely harm- 
less to the child, and that the children come to with- 
out stimulation or assistance/' 

Siegel then refers to Salzberger's investigations of 
all the data of scopolamin births up to 1910 — in- 
cluding those of the opponents — which proved that 
only 1.1 per cent, died within the first three days. 

Siegel concludes : 

" From this report of my experiments it is to be 
seen that preserved mannite-scopolamin has given 
complete satisfaction and is, in its biological effect in 
obstetrical practise, in no way inferior to the fresh 
solutions. 

" The most valuable fact is that we now have at 
last a constant scopolamin preparation. The direct 
consequence of this will be that we shall now be in a 
position to simplify considerably the formerly com- 
plicated method of Twilight Sleep. 

" For months past we have now been employing 
the Hoffman La Roche preparation of Straub's 
mannite-scopolamin, which is to be obtained under 
the name of ' Scopolia-Haltbar.' " 



XVI 

The Simplified Method Witnessed by the 
Visiting Physicians in the Sum- 
mer of 1914 

A GREAT many foreign physicians who visited 
the Freiburg Frauenklinik in the summer of 
1 914 were puzzled by the births which they wit- 
nessed in the fourth-class free ward. 

They said : " The method which we have seen is 
certainly not the one we have been led to expect 
from all we have heard of the Gauss Dammer- 
schlaf. ,, 

One American doctor complained : " There we 
stood — six of us — for days and nights with our 
ears stretched to hear the far famed ' memory test ' 
without ever getting the slightest satis faction. " 

The fact of the matter was, these visiting phys- 
icians were not witnessing the Gauss Twilight Sleep 
as it was still conducted in the first-class ward by 
Drs. Kronig, Gauss, and Schneider with scopolamin- 
morphin and the memory test, but they were observ- 
ing the experiments which were in progress in the 

271 



272 THE TRUTH ABOUT TWILIGHT SLEEP 

fourth-class ward with the " Siegel Simplified 
Method." 

In Dr. Siegel's former paper on his experiments 
with the Straub preserved scopolamin he gave us the 
first intimation that he believed with this new con- 
stant mannite-scopolamin it would be possible to 
simplify greatly the hither-to rather complicated 
Dammerschlaf ; with this theory he immediately 
went to work to develop a system of set, invariable 
rules to be conducted with invariable scopolamin. 

Formerly, even when every precaution was taken, 
by having fresh solutions and subjecting every solu- 
tion to the apatropin test by using permanganate 
of calcium, the scopolamin still showed a tendency to 
eccentricity; this factor consequently added materi- 
ally to the difficulties of the physician who not only 
had to use the most tactful adaptation of the method 
to the individual peculiarities of the patient and her 
condition, but had furthermore to adapt the dosage 
to the individual peculiarities of the especial solution 
being used. 

This was the greatest reason for the reiterated 
insistence of Gauss that only by the memory test 
could the effect be judged. 

It has already been pointed out that in the larger 
surgical doses variability of scopolamin was not as 



SIEGEL'S SIMPLIFIED METHOD 273 

noticeable as in the small, exact doses required in 
childbirth. 

Now that there was at last at hand a constant 
scopolamin, whose behavior could be counted upon 
with a great degree of certainty, its first effect was to 
eliminate a large degree of uncertainty in the results 
which could be expected from its employment. 

Of course nothing can ever change the fact that 
there are rare cases of patients with a peculiar idio- 
syncrasy to the drug, as well as to other narcotics, 
but these cases are so unusual they cannot be con- 
sidered when developing a method for the use of 
thousands of normal mothers. 

Dr. Siegel deserves great credit for trying to for- 
mulate a method for the medical masses, a method 
which requires no peculiar brilliance of technic, psy- 
chological discernment, or nerve-racking concentra- 
tion on the part of the operator. It means that here 
is a method which can be as easily employed in pri- 
vate practise as in the lying-in wards of hospitals. 

As one American doctor said to me in speaking of 
the Siegel method : " It will do this much without 
doubt — it will place Twilight Sleep on a simpler 
footing, whereby it will be within the scope of thou- 
sands of physicians of ordinary attainments, while 
the more psychological Gauss method could only be 



274 THE TRUTH ABOUT TWILIGHT SLEEP 

successfully conducted by the gifted and scientific 
hundreds." 

Dr. Siegel * says that since Gauss introduced Twi- 
light Sleep into practical obstetrical use in 1905 it 
has stood the test in many thousands of cases and 
that the method successfully attains its object of 
diminishing the suffering of mother or child. " All 
the objections raised by Bumm's clinic against the 
Dammerschlaf may be considered definitely refuted 
in all points by enormous numbers of cases. 

" Gauss's method, as I may be permitted to repeat 
briefly here, is based on the principle of regulating 
the scopolamin-morphin dosage by frequent repeti- 
tions of the memory test during the time of birth. 
What Gauss is aiming at is not to induce deep nar- 
cosis but a state which he calls Dammerschlaf. Al- 
though the woman in labor will utter complaints dur- 
ing pains, she retains no memory of her suffering. 
When Dammerschlaf is properly carried out the 
woman will not know anything of the events which 
have taken place during her Twilight Sleep, and she 
will therefore not remember any sensation of pain 
at birth. 

" This method has, of course, the disadvantage, as 

*" Painless Births in Dammerschlaf, by a Simplified 
Method," by Dr. P. W. Siegel, Assistant at the University 
Clinic of Freiburg. Published in Deutsche Medizinische 
Wochenschrift, No. 21, 1914. 



SIEGEL'S SIMPLIFIED METHOD 275 

has always been pointed out, that the progress of the 
birth has to be watched constantly by a trained nurse 
under the supervision of an experienced doctor. 
This requirement from the beginning limited the use 
of the Dammerschlaf to the clinical wards. We 
have, therefore, never employed it in private prac- 
tise. 

" We have always aimed at simplifying the 
method. But this was not possible as long as scopo- 
lamin was a drug the efficacy of which was subject 
to great variation. A simplification of the method 
of Twilight Sleep could, of course, only be obtained 
after we got a drug of unvarying effectiveness. At 
the same time the further condition had to be met 
that the zone between Dammerschlaf and deep nar- 
cosis should be wide and of limited variation in indi- 
viduals." 

Siegel believed that once provided with an alka- 
loid of unvarying efficiency, the effect upon indi- 
viduals would not be subject to any considerable fluc- 
tuations, as in Twilight Sleep the physicians have to 
deal with neither the very young nor the decrepit, 
but with women in the prime of life. 

" Straub's mannite-scopolamin, Scopolia-Haltbar, 
" Scopolamin durable" (Hoffman La Roche), has 
been found in our experience to meet this require- 
ment in a very large measure. Straub has proved 



276 THE TRUTH ABOUT TWILIGHT SLEEP 

the durability by experiments on animals, and I at- 
tained the same Dammerschlaf as that induced with 
fresh solutions. 

" As Gauss has already pointed out in his publica- 
tion, the dosage of morphin had to be most careful, 
as overdosing with morphin would in Twilight Sleep 
easily result in inconveniently long lasting, though 
harmless, apnea of the child.'' 

Dr. Schlimpert had earlier made experiments with 
another Straub product, narcophin, 2 which he found 
affected the centers of respiration much less than 
morphin. 

Dr. Siegel began experiments with this same nar- 
cophin when he attempted to simplify Twilight 
Sleep, and he found that it had no dangerous or 
menacing effects. 

Siegel' s procedure in simplifying the method was 
as follows : 

"At first Dammerschlaf was induced in a great 
number of cases according to the instructions given 
by Gauss, with preserved scopolamin and narcophin, 
using the memory test. After the birth, records 
were closely studied, and it was discovered that actu- 
ally the doses of scopolamin — ' durable ' and nar- 

2 Straub's narcophin is put on the market by Boringer 
Sohne. I made inquiries of the largest wholesale British 
chemists and was told that it is not to be obtained in England. 



SIEGEL'S SIMPLIFIED METHOD 277 

cophin necessary to attain a satisfactory Twilight 
Sleep varied but little in different individuals within 
a uniform period of time." 

With this clue to a uniform result obtained by con- 
stant scopolamin, Siegel's next effort was to plan 
some set rule of dosage which would eliminate the 
" individualizing " formerly necessary in the han- 
dling of every separate case. It is immediately evi- 
dent what a tremendous factor in the constitution 
of a simple, practical method this would mean. 

With positive regulations for exact dosage at ex- 
actly stated intervals, to be administered alike to 
every patient, the element of possible failure (be- 
cause of the lack of judgment or skill of the various 
operators) would be largely done away with. 

It is almost staggering to think of the tireless 
amount of conscientious experiment it must have 
taken before Siegel could arrive at a positive dosage. 
As he says : 

" It need scarcely be mentioned that the building 
up of this method has been preceded by a very large 
number of experiments. 

" On the basis of these experiments, excluding 
cases of abnormally debilitated women, a table of 
dosages for the whole duration of the birth has been 
compiled." 

I call your especial attention to the fact that with a 



278 THE TRUTH ABOUT TWILIGHT SLEEP 

worked-out system of set doses of invariable scopo- 
lamin, Siegel was now able to omit the memory test ; 
this, more than anything else, proves the positive and 
systematized results which he obtained, and further- 
more shows that at last a system of dosage had been 
found which could be administered to all patients 
without danger of overdosing. He says : 

" Every case was now treated systematically in 
accordance with this table and without any control 
by the memory test." 

You will observe in Siegel's method every third 
injection of scopolamin is combined with .015 g. nar- 
cophin. The doses are all given by hypodermic in- 
jections. Here is the table of doses to be adminis- 
tered at regular periods. 

TECHNIC 

" The dosage that has now been used by me in 220 
consecutive cases is as follows : 

Beginning with I 1 /* ccm. sco.-f- 1 ccm. narcophin = 
.00045 g. sco.-f-.03 g. narcophin. 

}i hours after beginning 1^2 ccm. sco.=.ooo45 g. sco. 

iy 2 hours after beginning y 2 ccm. sco.+ ^ ccm. nar- 
cophin =.00015 g. sco.-f-.015 narcophin. 

3 hours after beginning y 2 ccm. sco.=.oooi5 g. sco. 

^y 2 hours after beginning y 2 ccm. sco.=.oooi5 g. sco. 

6 hours after beginning y 2 ccm. sco.-|-^ ccm. nar- 
cophin =.00015 g. sco.-j-.015 narcophin. 



SIEGEL'S SIMPLIFIED METHOD 279 

jy 2 hours after beginning y 2 ccm. sco ==.00015 %- sc0 - 
9 hours after beginning ]/ 2 ccm. sco.=.oooi5 g. sco. 
\o x / 2 hours after beginning y 2 ccm. sco.-j- l A ccm. nar- 
cophin =.00015 g. sco.-f-.015 narcophin. 

and so on every iy 2 hours l / 2 ccm. scopolamin 
(.00015 £•)•" 

The greatest proof of the lack of great depth of 
this narcosis is shown in the fact that, unlike the 
Gauss Dammerschlaf, it becomes necessary in the 
Siegel method to employ a slight chlorethyl nar- 
cosis, in addition to the scopolamin and narcophin, 
at the actual passing of the head of the child. 

With the Gauss Dammerschlaf there is no neces- 
sity for this addition of chlorethyl, as the injections 
of scopolamin-morphin tide the patient as success- 
fully over the climax of birth as through the ordi- 
nary labor pains ; moreover, in the Gauss Dammer- 
schlaf the amnesia of the patient, where the passage 
of the head is concerned, is just as perfect as the ob- 
literation of the memory of the rest of the process 
of birth. 

Of the necessary addition of chlorethyl, Siegel 
says: 

" It should be especially mentioned that when the 
head is cutting through, a small dose of chlorethyl of 
about 10 ccm. should be administered with the Her- 
renknecht mask. This is necessary, as Dammer- 



28o THE TRUTH ABOUT TWILIGHT SLEEP 

schlaf is a condition half way between waking and 
sleeping. The Dammerschlaf is sufficient to obliter- 
ate the memory of the usual labor pains, but it is not 
sufficient to maintain amnesia during the most pain- 
ful moment in the act of birth, the passing of the 
head." 

Siegel overlooks the fact that the Gauss Dam- 
merschlaf is also " a condition half way between 
waking and sleeping/ ' and yet is sufficient to " main- 
tain amnesia during the most painful moment in the 
act of birth." 

Siegel continues, as if in answer to expected criti- 
cism : 

" One might think that for the sake of simplicity 
the Dammerschlaf ought to be deepened somewhat 
rather than introduce this new complication. A 
deeper Dammerschlaf, however, would necessitate 
larger quantities of narcotics, A chlorethyl narcosis 
of 10 ccm., as is well known, has scarcely any effect 
on a person, at any rate it never does any harm. 3 

3 Chlorethyl was first used as an anesthetic by Flourens in 
1847, but it was almost forgotten until 1804 when it was re- 
discovered by a Swedish dentist named Carlson. It is closely 
related to bromethyl and produces a narcosis of very limited 
time. Many obstetricians, including Maurette, Lop, and 
Kronig, recommend it for obstetrical operations as excellent 
and harmless. It is said to be less dangerous than bromethyl 
and has less after effect. Its immediate effectiveness makes 



SIEGEL'S SIMPLIFIED METHOD 281 

With a larger dose of scopolamin and of narcophin, 
however, the secondary effects might occur in a more 
pronounced manner. For this reason we prefer the 
chlorethyl narcosis." 

Granting that chlorethyl is harmless, it is interest- 
ing to find him adding: "this chlorethyl narcosis is 
not always necessary. Only experience will enable 
the physician to decide whether the use of chlorethyl 
is advisable or not. It is only, so to speak, a safety 
valve by means of which the Dammerschlaf can be 
satisfactorily attained in a larger percentage of 
cases. 

" I had set myself the task of rendering the con- 
duct of Twilight Sleep as independent as possible of 
individual dosage, and this apparently could best be 
done by supplementing the Dammerschlaf by chlor- 
ethyl." 

We cannot lose sight of the great effectiveness 
achieved by Gauss by his system of tactfully applied 
individual dosage, yet even though the Gauss method 
may be greater and its results unassailable, yet we 
must not forget that to get the same results which 
Gauss obtained the greatest conscientious care on the 
part of the operator is necessary, and Siegel is trying 

it very valuable, but Kronig warns against prolonging a 
chlorethyl narcosis over a few minutes. 



282 THE TRUTH ABOUT TWILIGHT SLEEP 

to formulate a method devoid of difficulties for the 
physician. 

Where injections of unvariable quantities are in- 
jected at stated times, overdosing (unless the injec- 
tions were kept to the smallest effective quantity) 
would be much more apt to occur than when the in- 
jections were scientifically administered according 
to the apperception of the patient as judged by the 
memory test. Keeping the set doses down to their 
minimum effectiveness, it is perhaps unavoidably 
necessary to deepen the narcosis by the addition of 
chlorethyl at the passing of the head; as Siegel says, 
it would be very discouraging to see the result of a 
Dammerschlaf, which had been successfully sus- 
tained for hours, rendered doubtful at the end, when 
by the administration of a small dose of chlorethyl it 
could be terminated triumphantly. 

Of the time limit of this method Siegel says : 
" Dammerschlaf may be induced as soon as the ob- 
stetrician is satisfied that the birth process has be- 
gun, i.e., as soon as regular pains occur at opening of 
os. It is, as a rule, not necessary to await a definite 
opening of the os. I have successfully begun the 
Dammerschlaf when the os was only two-thirds of 
an inch to one inch in diameter as well in primi- 
parae " (first child) " as also in multipara " (where 



SIEGEL'S SIMPLIFIED METHOD 283 

the mother has had other children), " and I have not 
observed any protraction of labor. The pains of 
labor are, as a rule, called regular if in primiparse 
they occur every five minutes and in multipara in 
from five to six minutes. It is in this stage gener- 
ally that the labor also begins to become painful to 
the woman. It is less a question of labor having 
reached a certain stage, than that the process of birth 
is under way at all. 

" In my 220 cases I was not obliged in a single in- 
stance to interrupt the Twilight Sleep. If once be- 
gun, the Dammerschlaf could be carried through to 
the birth. Once, for instance, I maintained Twi- 
light Sleep for thirty-one hours, once for thirty- 
three and in another case for thirty-nine hours with- 
out any symptoms of danger to mother or child hav- 
ing appeared. With the long duration of the Dam- 
merschlaf, of course, the total dose of scopolamin 
and narcophin increases. The largest number of in- 
jections given by me were twenty- four, twenty-five 
and twenty-seven injections. This means a nar- 
cophin dose twice of .15 g. and once of .165 g. and a 
scopolamin dose of .00405 g. .00435 g., and .0048 g. 
As these doses are distributed over a long period of 
time they are still below the maximum doses. At an 
average, of course, we use much less narcotics, as 



284 THE TRUTH ABOUT TWILIGHT SLEEP 

the birth will take its course within a much shorter 
time. At an average we gave six injections with .06 
g. narcophin and .0015 g. scopolamin. 

" Besides primary weakness of labor there is no 
counter indication against the use of Dammerschlaf. 
Even in such cases it is doubtful whether it might 
not be used, but we have no experience in this re- 
spect." 

Even in cases of narrow pelvis, Siegel says his 
method may be carried out with good results. 

" Especial preparations for the Dammerschlaf are 
not necessary. We have only to take care that the 
patient is talked to as little as possible, that there is 
no noise around her, and that the light does not fall 
directly on her face. Curiously enough, under Twi- 
light Sleep women are remarkably sensitive to light. 
I therefore cover the woman's face with a handker- 
chief toward the termination of the birth as several 
times the patients stated that they knew nothing of 
the birth, but they had suddenly realized that many 
people were standing around them and that there had 
been a flood of light. This latter was the search 
light. 

" It has to be taken into consideration that 197 
cases were treated in the public delivery ward, with- 
out the women being isolated. ,, 

One hundred and ninety-six births were spon- 



SIEGEL'S SIMPLIFIED METHOD 285 

taneous. Not including two cases of breech pres- 
entation, the proportion of operations was 10 per 
cent. 

For comparison, Siegel compiled the operative sta- 
tistics from the records of 1,000 consecutive births in 
which no narcotics had been used and found that 
there were 105 operations among this number — 
10.5 per cent. Comparison of his figures with these 
shows his results to have been good. 

" I must here draw attention to a very interesting 
fact. Among the seventy-eight spontaneous births 
there occurred only six times slight ruptures of the 
perineum = 7.5 per cent. Among the forty-nine 
cases of spontaneous second births and the eighteen 
spontaneous third births there was no rupture of 
the perineum. This great reduction of perineal 
rupture is very striking." 

Having collected the records of 800 consecutive 
first births without scopolamin he found the record 
to be " percentage of rupture of the perineum 13.5 
per cent." — that is, almost double the Siegel fig- 
ures. 

In only six cases did Siegel protect the perineum. 

" This is proof," says he, " how very quietly the 
head passes over the perineum and how little the ob- 
stetrician is troubled by the woman in labor. 

" A special advantage of the Dammerschlaf is that 



286 THE TRUTH ABOUT TWILIGHT SLEEP 

if minor operations are necessary they can be carried 
out successfully in chlorethyl narcosis." 

Of the results of his fixed dosage, Siegel says : 

" Of the 220 mothers 193 had complete amnesia; 
that is> about 88 per cent. These women know- 
nothing of the birth process passed through. With 
the exception of thirteen cases all had been adminis- 
tered chlorethyl narcosis. 

"Of the 193 cases of complete amnesia only 
twenty-three, that is 12 per cent., recollected having 
smelt something or to have had a mask on the face. 
This recollection corresponds with the administering 
of chlorethyl. These are the cases then in which we 
may presume that the birth pangs would have been 
felt but for the chlorethyl intoxication. In all the 
other cases therefore chlorethyl was superfluous. 
It is difficult, however, to gage the necessity for the 
use of chlorethyl, and as it is really harmless, it may 
always be used conscientiously. 

"In twenty-two cases (19 per cent.) partial suc- 
cess was obtained, as sometimes the patients stated 
to have felt the birth but could not account for long 
spaces of time during the birth process, or in other 
instances they spoke subjectively of a quite distinct 
diminution of pain. 

" In five cases = 2 per cent., the injections had no 
effect as they were administered too late. . . . 



SIEGEL'S SIMPLIFIED METHOD 287 

" Amnesia has been ascertained by me in the fol- 
lowing manner: After the birth I used to ask the 
mothers whether they had already had their child, 
whether they had noticed any smell, whether they 
had had a handkerchief laid on their face and how 
many injections they had been given. It was found 
that amnesia begins between the second and third in- 
jection. 

" Of the 193 cases of complete amnesia, 128 only 
remembered two injections, 49 three, 15 four, and 
2 more than five injections. If we compare these 
figures with the table of dosages we see that Dam- 
merschlaf sets in at an average between Y\ and i l /> 
hours after the first injection. . . . 

" In 30 instances I have asked the women how 
long they reckoned to have lain from the time of the 
first injection until waking from the Dammerschlaf, 
and without exception they greatly underestimated 
the length of time. It is surprising to hear from a 
patient who has been sleeping from twenty-five to 
thirty hours, that she believes the birth only lasted 
three or four hours. From this it is evident that 
we had favorable results even in those cases where 
the patient by accident felt the birth but was other- 
wise under amnesia during a large part of the time ; 
in other words, the larger number of cases which I 
have classified as partial success represent by them- 



288 THE TRUTH ABOUT TWILIGHT SLEEP 

selves a satisfactory result. If, for instance, such a 
mother had been kept in Dammerschlaf for twenty 
hours, she would have the impression that she per- 
haps felt the birth but that it lasted a short time 
only, say from three to four hours. ... If the 
Dammerschlaf has lasted over twenty- four hours, it 
affords a curious spectacle to see how the woman's 
reckoning of time is displaced by an entire day. 
She wakes up, for instance, on Tuesday morning 
and will not be persuaded that it is not Monday 
morning. 

" Pronounced secondary effects are cited as an 
argument against the Dammerschlaf. Above all, 
stress is laid upon the statement that the births are 
extraordinarily delayed and that protraction of labor 
is caused by it. Pronounced protraction of labor I 
have observed only in 3 cases. In 28 cases there 
was moderate or only slight protraction. In 189 
cases I did not notice any protraction of labor. I 
beg to state explicitly that among my cases there 
were 12 primiparse of over thirty-one years of age. 
The oldest of these was thirty-nine years of 
age. . . . 

"I have to draw the attention to the fact that 
every doctor when seeing Dammerschlaf births for 
the first time implicitly gets the impression of a pro- 
traction of labor and shortening of pains. This im- 



SIEGEL'S SIMPLIFIED METHOD 289 

pression arises as the woman in Twilight Sleep 
usually only feels the pains when at their height 
and utters only slight complaints or no complaints 
at all. Whereas, a woman in full consciousness ut- 
ters complaints at the mere approach of pains and 
even long afterwards. In my opinion this easily 
explains the subjective impression of protraction of 
labor and abbreviation of pains, whilst by laying 
the hand on the patient's body the frequency and in- 
tensity of labor will be noticed to be much more fav- 
orable. 

" Other side effects, especially those of scopo- 
lamin, are redness of the face, slight agitation, and 
vomiting. But all these states occur far less fre- 
quently than is always supposed. In 132 cases I 
did not notice any side effects whatever. In 73 
cases flushing of the face occurred, in 58 cases agita- 
tion, 5 patients vomited. Reddening of the face is 
purely peripheral hyperemia 4 without any signifi- 
cance. This is shown by observation of the pulse, 
for the heart beats in my cases rose above 100 per 
minute in only nineteen instances, and even in these 
few instances the pulse never presented any threat- 
ening symptoms. 

" The excitement of the patients is generally 
slight. I have observed really great excitement in 

* Excess of blood only in the outer surface. 



290 THE TRUTH ABOUT TWILIGHT SLEEP 

six cases only. Our low number of cases of rup- 
ture of the perineum proves that the state of agi- 
tation is not so very great. If the patient would 
toss about, as has often been said, it would not be 
possible properly to protect the perineum, and there 
would be very frequent ruptures in conse- 
quence. . . . 

" I have never been able to observe in any mother 
that the breathing center having been influenced by 
narcophin, caused a slackening of the breath. In 
139 cases the breaths have been counted every three 
hours and they were found never to be less than six- 
teen nor more than thirty per minute. 

" Further side effects there are none of any con- 
sequence. ,, 

AFTERBIRTH 

" Afterbirth hemorrhages (atonies in connection 
with scopolamin), such as have been cited over and 
over again, have never been observed by me. The 
losses of blood have been measured by us, and only 
in 16 cases we ascertained a loss of blood exceeding 
500 g. Only in 2 cases these heavy hemorrhages 
had to be ascribed to atony" (want of tone — ab- 
normal relaxation) . " Two hundred and nine times 
it was not necessary for us to take any steps on ac- 



SIEGEL'S SIMPLIFIED METHOD 291 

count of loss of blood. We had to prescribe styptic 
medicine " (to cause contraction of tissues of the 
blood vessels), "such as secacornin, only in 2 
cases. . . ." 

CHILDBED 

" In childbed also, as a rule, we had no symptoms. 
Two hundred and five mothers were able to leave 
the clinic within the first ten days after parturition; 
the remaining 15 mothers showed only slight in- 
crease of temperature. One hundred and ten pa- 
tients got up for the first time on the first day, 10 
patients on the second day after the birth. With the 
exception of one woman, all patients made gymnas- 
tical exercises. One hundred and sixty-one women 
did not complain about thirst, 44 had moderate, and 
15 women had a lasting sensation of thirst. But 
even in these cases the dryness of the mucous mem- 
branes is far less than that observable in operations. 
Two hundred and thirteen mothers were able to 
nurse. The other seven did not nurse on account of 
the death of their children. Only in 2 cases was the 
milk secretion not sufficient There is, therefore, 
no reason to talk about the Dammerschlaf having a 
harmful influence upon childbed or lactation." 



292 THE TRUTH ABOUT TWILIGHT SLEEP 

THE CHILDREN 

"Of the 220 infants, 148 were born absolutely 
lively. Sixty-one were oligopneic, 4 apneic, and 4 
asphyctic. Two children were stillborn, and one 
child had to be perforated on account of fever in the 
mother. Of the asphyctic children, two were re- 
suscitated successfully, the other two died after 
three-fourths of an hour and one and one-half hours 
of efforts at resuscitation. The condition of the 
children expressed in per cent, reads as follows : 

per cent. 

148 lively children =67.6 

61 oligopneic children =27.7 

4 apneic children = 1.7 

2 asphyctic children, lived = 0.85 

2 asphyctic children, died = 0.85 

3 still-born children = 1.3 

" The mortality of the children at birth is there- 
fore extraordinarily low — 2.15 per cent, including 
the two asphyctic children. . . . 

" Of the 220 children, 213 left the clinic alive and 
healthy. The total mortality at birth and within the 
first days of life is only 3 per cent. This is a very 
good result and corresponds completely with obser- 
vations hitherto made on scopolamin children. 

" On the basis of this low infant mortality it ap- 



SIEGEL'S SIMPLIFIED METHOD 293 

pears scarcely justified to attribute to Twilight Sleep 
a harmful influence on the children. 

" It is seen also that the often objected to state of 
oligopnea is absolutely harmless to the infant's life. 
Oligopnea, according to Gauss, is a state of slight 
intoxication of the child, a certain percentage of 
which can, unfortunately, not be avoided. The 
heart is beating actively, and when blown upon or 
touched, the children made defensive movements. 
The oligopnea in 34 cases lasted up to five minutes, 
in 21 cases up to ten minutes, and in 4 cases up to 
fifteen minutes, in 1 case twenty, and in another 
twenty-five minutes. 

" In order to see how the oligopneic children be- 
have without assistance, I have in 22 cases not taken 
any steps whatever. I laid the children on the table 
and did not interfere with them. All these chil- 
dren attained a normal condition unaided by me 
within the above mentioned time limits. Among 
these unassisted children there was also the case of 
oligopnea lasting twenty-five minutes. I believe 
that this is sufficient proof that oligopnea by itself 
does not need any treatment, and that an oligopneic 
child will recover a lively condition without assist- 
ance. I frankly admit that with insufficient ex- 
perience it is rather difficult to distinguish between 
oligopneic and apneic children. One lacking ex- 



294 THE TRUTH ABOUT TWILIGHT SLEEP 

perience ought to assist such children with slight 
mechanical stimulation. This treatment will not do 
any harm. If the case was oligopnea, the treatment 
was superfluous; if it was apnea, nothing had been 
omitted. 

" In order to afford a survey of my cases, I may 
only mention that in 167 cases no treatment was 
given to the children. . . . 

" The child is harmed by Twilight Sleep as little 
in its extra-uterine " (after-birth) " life as it is en- 
dangered by its intra-uterine " (before birth). 
" The Dammerschlaf has no influence upon the 
fetus's heart sounds. . . . 

" When leaving the clinic, 36 children had reached 
or passed their weight at birth. If we consider that 
only 12 women stayed longer than ten days at the 
clinic, the variation in the weight of the children may 
be accepted as absolutely normal. A diminution of 
the weight of a child by more than one pound has 
never been observed. 

CONCLUSION 

" A resume of my experiences shows that we pos- 
sess in the combined mannite-scopolamin-narcophin 
treatment, as per my table of dosages, a very handy 
method of Twilight Sleep. But it is not absolutely 
ideal. However, with its 88 per cent, of com- 



SIEGEL'S SIMPLIFIED METHOD 295 

plete success and the 10 per cent, of partial success, 
its insignificant side effects on the mother and child, 
it represents to-day the best of all known methods 
for lessening pain at childbirth. 

" Its advantage consists in the easy technic. Any 
individual preparation in each case is superfluous. 
Every patient is given mechanically, at the exact 
periods stated, the prescribed doses of scopolamin 
and narcophin. 

" The rest of the birth process takes place with ex- 
actly the same accidents or complications that may 
occur also in any births without Dammerschlaf. 

" I know very well that with greater experience 
some cases may be treated more individually ; that in 
many patients a smaller dose, and in others a slightly 
larger dose would give better results. But I have 
adhered to the table of dosages on principle, as I 
wanted to work out a simplified method. 

" The number of 220 cases is still so small that I 
would not care to recommend this method for gen- 
eral practise, but I believe that it is well worth being 
tested in other clinics in order rapidly to accumu- 
late more data of observation.'' 

Apropos of the Siegel method, I want to tell you 
of a representative case of an American visiting 
physician ; this woman doctor came to Freiburg with 
only ten days left before her return to America; 



296 THE TRUTH ABOUT TWILIGHT SLEEP 

after witnessing (together with another woman 
physician from Maine and four male American doc- 
tors) five births in the fourth-class ward, she found 
herself in a fearful state of perplexity, indecision, 
and even fright. 

She had heard much of the "Gauss Dammer- 
schlaf " in the Berlin, Munich, and Vienna clinics, 
and she had come to Freiburg to study, as far as she 
could in that length of time, the Gauss method,. be~ 
cause she had a friend in Canada of thirty-eight 
years of age who was to soon give birth to her first 
child and this doctor believed Twilight Sleep would 
be just the thing for this case. 

It occurred to none of the Frauenklinik German 
doctors in the fourth-class ward to explain to these 
visiting physicians that the new Siegel method was 
there being tried out. 

The first shock to the Americans was that no 
memory test was used ; then they found morphin sup- 
planted by narcophin; moreover, as accident so de- 
creed, all five of the first children whom they saw 
born were oligopneic, and the inexperienced phys- 
icians of the fourth-class ward hurriedly used arti- 
ficial means to revive them. 

One of the other doctors who witnessed these 
same five births said : " If I had charge of such 
births I would be gray in a week." 



SIEGEL'S SIMPLIFIED METHOD 297 

To show you further to what conclusion even ex- 
perienced physicians may wrongly arrive, one of 
these doctors told me, with horrified, frightened 
face, that the oligopneic condition of the children 
was so dreadful that the German doctors in the 
fourth-class ward actually had to run a tube down 
the children's throat and pump air into them ! 

Curiously enough, the following day at the uni- 
versity library, while hunting in the Munich Medical 
Weekly for something else, I came across an article 
on the use of the " tracheal catheter " for removing 
the amniotic fluid from the bronchial tubes of the 
child, and it suddenly occurred to me that this was 
what the visiting physicians had seen at the Frauen- 
klinik. 

I hastened to communicate my supposition to the 
American doctor, but I found that she had already 
had her mind relieved that very day by being told by 
one of the Frauenklinik physicians that the use of 
the tube had nothing whatever to do with oligopnea, 
but was only an extra precaution taken to remove 
any possibly inhaled amniotic fluid from the child's 
tubes. 

To show the great state of general alarm of this 
physician (who was the most absolutely conscien- 
tious doctor I have ever met), she then asked me — 
knowing of my preparations for this book : 



298 THE TRUTH ABOUT TWILIGHT SLEEP 

" Do you realize your great responsibility ? " 

She meant, did I realize that I was recommending 
all women to urge their physicians to adopt a 
method which she believed, after witnessing five 
births, to be dangerous to the child. It will be in- 
teresting to see how her opinion was later on 
changed. 

I introduced her to an American mother who had 
just been delivered a few days before by Drs. 
Kronig and Gauss. After hearing this mother's 
experience, the physician was in a worse state of 
puzzlement than ever, for the American mother told 
of the memory test. Her husband corroborated 
and enlarged on all her statements from his observa- 
tion of the early stages of the birth — before he was 
expelled from the room by Dr. Gauss. 

The husband assured the doctor that he had 
heard the memory test applied, and that morphin, 
not narcophin was used — here he handed her the 
Frauenklinik record of his wife's delivery with the 
quantities of the injections clearly stated and all 
other details of the birth. Furthermore, he had 
seen his son immediately after birth and he was 
certainly not oligopneic, but crying and kicking 
lustily while his mother calmly slept on unperturbed. 

" Why ! " exclaimed the American doctor, " I am 
listening to the description of an entirely different 



SIEGEL'S SIMPLIFIED METHOD 299 

method from the one I have seen in the fourth 
ward." 

Her state of perplexity was so great she felt noth- 
ing could clear it but a conversation with Dr. 
Kronig himself. After telling all her conflicting 
impressions to Dr. Kronig, he explained to her that 
the physicians and nurses of the fourth-class ward 
were trying out a simplified method of Dr. Siegel's 
which was not synonymous with the Gauss Dam- 
merschlaf as conducted in the first-class ward. 

On hearing the American's alarm at the condition 
of the children at birth, Dr. Kronig said, that while 
the Siegel method was as yet only in the experi- 
mental stage " it is at least already helping to lower 
the already low infant mortality statistics of the 
Frauenklinik." 

Kronig was violently upset over hearing of the 
artificial efforts at resuscitation of the infants re- 
sorted to by the fourth-class physicians, excitedly 
exclaiming : " It is entirely unnecessary — it is all 
foolishness. It is their inexperience that makes 
them think it necessary. I will see to it immedi- 
ately." 

With a better understanding of the conditions and 
the two different methods of Dammerschlaf, the 
American doctor returned to her investigation of 
the births under the Siegel method, and in four days 



300 THE TRUTH ABOUT TWILIGHT SLEEP 

her whole attitude of mind had cleared and changed. 

" I am thankful that I could be here for the last 
four days and nights," she declared at leaving; " it 
has changed my whole opinion of scopolamin-mor- 
phin; but alas! several of the other doctors, who 
witnessed the first series of births, have gone before 
there was a chance of their understanding and com- 
ing to different conclusions. 

" During those first five births I felt convinced 
from the start of the absolute safety and benefit to 
the mother, but I felt alarm for the safety of the 
child ; now I have changed the latter opinion entirely 
since a more thorough investigation of the oligop- 
neic condition. 

" Since my conversation with Dr. Kronig, the 
babies have been left alone in the fourth-class ward, 
and just as he said, they have revived of their own 
accord within fifteen minutes. 

" Moreover, I find that it only so chanced that all 
the first five children were born oligopneic; in the 
last four days and nights the majority of children 
have been born in an absolutely normal condition. 

M Now, too, that I thoroughly understand the 
Siegel method of fixed dosage, which can be used 
without the memory test, I have come to a still more 
important conclusion, and that is that scopolamin is 
not the dangerous drug it has been supposed to be. 



SIEGEL'S SIMPLIFIED METHOD 301 

I feel that in order really to know anything of Twi- 
light Sleep, a physician should remain at the 
Frauenklinik for a year, but as that is now impossi- 
ble for me I shall have to make the best of my 
ten days' and nights' investigation and with a full 
realization of my inadequate preparation I shall 
nevertheless try the method as soon as I get home 
with a determination to work it out conscientiously 
for myself in the form of a combined Gauss and 
Siegel Dammerschlaf. I now believe entirely in the 
use of scopolamin-morphin in childbirth. I believe 
it is absolutely safe for the mother, that it ensures 
her painlessness and a quick recovery after birth, 
and I believe that it is absolutely safe for the child." 
This woman physician's opinion is worth listen- 
ing to, as she has a record of twelve years of ma- 
ternity cases with only one case of forceps. 



XVII 

The American Physicians and Painless 
Childbirth 

THROUGHOUT the American medical press 
have been published articles severely criticiz- 
ing the publicity given Twilight Sleep. 

We are accused of pretending to discover a new 
method which — to quote the Journal of American 
Medical Association — " while not entirely obsolete, 
has been practically discarded." 

Do the records in this book make it appear that 
the method is either new or obsolete ? 

The American Journal of Clinical Review says: 

" The procedure is already well-known to thou- 
sands of physicians in the United States who have 
unostentatiously practised it for at least a decade. 
To suggest that Kronig and Gauss have a monopoly 
on this painless childbirth business by means of sco- 
polamin-morphin — that is to laugh." 

If the American physicians have been " unosten- 
tatiously practising " this method for at least a 

302 



AMERICAN PHYSICIANS' POSITION 303 

decade, why have we American mothers heard noth- 
ing of it? 

It is fortunately quite true that Kronig and Gauss 
no longer have a " monopoly " of the method, as the 
many records of other obstetricians which I have 
collected prove. It is, moreover, being used in 
Great Britain with especial success. 

When my article on " Painless Childbirth " was 
published in The Ladies' Home Journal, the opin- 
ions of " Eminent Obstetricians " were simultane- 
ously published. 

They are as follows : 

THE OPINIONS OF EMINENT AMERICAN 
OBSTETRICIANS 

" The use of scopolamin-morphin as an anesthetic 
in labor is no new thing: introduced by von Stein- 
biichel in 1902, it has been tried in this country, as 
well as in Europe, by numerous obstetricians. My 
own observations, published in 1903, led me at the 
time to favor this therapeutic means of producing 
the ' Twilight Sleep ' and removing the conscious- 
ness of pain, or at least preventing all remembrance 
of it. I have long since abandoned this agent, how- 
ever, for two reasons : 

" First, because it has apparently been the cause 
occasionally, of fetal asphyxia. 



304 THE TRUTH ABOUT TWILIGHT SLEEP 

" Second, because the effect of the drug on the 
mother is often uncertain, and unless used with 
great care may cause unfavorable or dangerous re- 
sults. 

" Moreover, we have other and safer measures 
for the relief of pain in labor. So I have given up 
teaching the use of scopolamin in my lectures. 

" Charles M. Green, M.D., 
" Professor of Obstetrics and Gynecology 
in Harvard University." 

" We have used the scopolamin treatment of 
childbirth in two separate series of cases at the 
Johns Hopkins Hospital. But in neither series were 
the results satisfactory, nor did they in any way ap- 
proach the claims made for the treatment. We ex- 
pect to do more with it next year. In the meantime 
my own experience and conversation with Profes- 
sor Kronig do not make me feel that the method 
really constitutes a great advance over those which 
are in use by American physicians. 

" J. Whitridge Williams, 
" Professor of Obstetrics, Johns Hopkins Medical School." 

" The mitigation of pains of childbirth has always 
been the anxious concern of physicians all over the 
world, but more than ever since the discovery of 
chloroform and ether and their use for this purpose. 



AMERICAN PHYSICIANS' POSITION 305 

In recent years several methods have been proposed 
that it was hoped might prove superior to the agents 
formerly used. Among these was the hypodermic 
injection of morphia and scopolamin to produce 
semi-consciousness and indifference to pain, or what 
the Germans call ' Twilight Sleep.' As long ago as 
1903 a monograph appeared in Vienna, advocating 
this treatment. American physicians, quite as pro- 
gressive as any others in the world, tried this 
method in our largest maternities. Among other 
places it was employed in the Maternity of the Uni- 
versity of Pennsylvania, in a series of cases over a 
period of two years. My experience with it coin- 
cided with that of my colleagues in this and other 
parts of the world. If enough morphia was given 
to abolish pain there is too much danger of hemor- 
rhage in the mother and asphyxia in the child. The 
scopolamin does not diminish pain, but simply quiets 
restlessness. 

" As a member of the Gynecological Touring 
Club of America, in the summer of 191 2, I had the 
privilege of observing this method at Freiburg in 
the clinic under the superintendence of Professors 
Kronig and Gauss. It was interesting to hear that 
the morphia was employed in a single moderate 
dose, followed by small quantities of scopolamin. 
Evidently the disadvantages of the treatment — 



306 THE TRUTH ABOUT TWILIGHT SLEEP 

hemorrhage and asphyxia — had necessitated this 
modification. My conclusion from this observation 
and from my own experience was that the quantity 
of two drugs being insufficient to abolish pain, the 
results secured in this clinic were partly psycho- 
logical — that is, the patients were assured before- 
hand that there would be no suffering; were deliv- 
ered in a quiet dark room ; were given one moderate 
dose of morphia and became temporarily under its 
effect; and, being told afterward they had had no 
pain, probably left the institution impressed with 
that belief. 

" Barton Cooke Hirst, M.D., 
" Professor of Obstetrics, University of Pennsylvania." 

" In November, 191 3, I spent four weeks in Frei- 
burg and had the opportunity to observe personally 
and study critically about ten cases of childbirth 
conducted in Professor Kronig's own clinic. The 
impressions received and opinions formed were de- 
cidedly unfavorable to the method of ' Twilight 
Sleep.' 

" In all ten cases the birth pains were weakened 
and labor prolonged; in two of the women for al- 
most two days. In three cases pituitrin had to be 
given to save the child from imminent asphyxia. 

" In five cases instruments had to be used. In 



AMERICAN PHYSICIANS' POSITION 307 

my opinion two of these were directly rendered 
necessary by the paralyzing effects of the drugs sco- 
polamin and morphin. Extensive lacerations re- 
sulted. 

" Several of the women became delirious and so 
unruly that ether had to be administered in addition 
to the scopolamin and morphin, the result being 
that the infants were born narcotized and asphyxi- 
ated to a degree. One had convulsions for several 
days. 

" All these occurrences confirmed my own experi- 
ence with the drugs. I had used them when first 
proposed twelve years ago. At that time they were 
extensively employed in Europe and America, but 
were soon discontinued because they were found 
impractical and dangerous. 

" I visited the famous maternities of Berlin, 
Vienna, Munich, and Heidelberg; in all of them 
upon inquiry I was told that this method had been 
tried and discarded. 

"Joseph B. De Lee, A.M., M.D., F.A.C.S., 
" Professor of Obstetrics, Northwestern University Med- 
ical School; Obstetrician to the Chicago Lying-in 
Hospital, etc., Author of * Principles and Practice of 
Obstetrics/ ' Obstetrics for Nurses/ etc." 

It does not seem characteristic of American jus- 
tice to issue such blanket rejections as are contained 



308 THE TRUTH ABOUT TWILIGHT SLEEP 

in the foregoing repudiations of Twilight Sleep. 

The most effective surface weapon which can be 
brought to bear on anything is to say, " I have tried 
it and it has failed." But we have a right to ask, 
" How did you try it?" 

Did these obstetricians observe the carefully 
worked out regulations of Gauss — the man who 
after laborious experimentation was at last able to 
formulate rules of procedure by which successful 
results could be obtained ? 

How many of the obstetricians have ever read 
the Gauss publications? 

If these eminent doctors have failed so signally 
where so many European obstetricians have suc- 
ceeded, then it is clearly evident that the American 
methods of Twilight Sleep need entire revolution- 
izing. 

The other reports which you have read from 
many different parts of the world prove that when 
scopolamin-morphin is properly employed it consti- 
tutes a safe, reliable method for the relief of women 
in childbirth. 

Let us take up these condemnations in turn. 

Dr. Green of Harvard has abandoned Twilight 
Sleep (i) "because of asphyxia of the child." 

Let a European obstetrician answer this objection 
for us. 



AMERICAN PHYSICIANS' POSITION 309 

Dr. Max Salzberger of Kulm says : 

" Only could asphyxia ever be proved to be due 
to scopolamin where it can also be proven that the 
injections caused an abnormal length of birth. For 
this, statistics would have to be kept of asphyxiated 
children born both with and without scopolamin in- 
jections." 

If Dr. Green means by asphyxia that state of in- 
toxication in the child known in Germany as oli- 
gopnea, then I shall ask you to turn back to Chapter 
XII. 

Asphyxia and oligopnea are two entirely different 
conditions. Asphyxia is always extremely danger- 
ous, while oligopnea is a temporary intoxication of 
the child which is conceded by general medical opin- 
ion to be without danger. 

When a child is born in this intoxicated condition 
it is proof that the mother has been inadvertently 
overdosed, and overdosing can be avoided if the 
doctor employs the proper precautions ; therefore a 
high per cent, of oligopneic children is an arraign- 
ment of the obstetrician and his careless technic, 
not of the method. 

(2) " Because the effect of the drug on the 
mother is often uncertain, and unless used with 
great care may cause unfavorable or dangerous 
results." 



3 io THE TRUTH ABOUT TWILIGHT SLEEP 

Regarding the uncertain effect upon the mother, 
as we know from the doctors' records, there are 
very rare instances of patients who show an indi- 
vidual idiosyncrasy to scopolamin ; but, as Tichauer, 
Kronig, and many other physicians point out, it 
would be most unfair to deprive thousands of 
women of the relief of Twilight Sleep, because of 
the eccentric constitution of one woman in, say, five 
thousand. 

The mothers, whose experiences I have tran- 
scribed in this book, were not selected cases. Cer- 
tainly none of these women reported uncertain 
results and their experiences are entirely character- 
istic. 

In sixty-nine medical reports, only one doctor re- 
ports that there was any dissatisfaction with the 
method on the mother's part — two patients of Dr. 
Preller's expressed dissatisfaction. (See Chapter 
VIII.) 

Any method of narcotization necessitates " great 
care." We surely have a right to expect and de- 
mand from all physicians great care in the use of 
any chemical. 

Those obstetricians who have followed Gauss's 
instructions to the letter, who have conducted the 
Dammerschlaf with " great care," do not report 
" unfavorable or dangerous results." 



AMERICAN PHYSICIANS' POSITION 311 

If a medical procedure is to be shunned merely 
because it demands great care on the part of the 
operator, then all major operations should be 
avoided for the same reason. 

(3) "Moreover, we have other and safer meas- 
ures for the relief of pain in labor." 

Surely the world has a right to share Dr. Green's 
secret. 

Europe would rejoice to hear of these " safer 
measures " for, as August Johnen of Mankarthof 
says: 

" At any rate the scopolamin-morphin narcosis is 
the one which is to-day the best with regard to 
lessening the suffering at birth, and it surpasses the 
semi-narcosis of chloroform and ether on account 
of its easier and more convenient application as well 
as because of its less dangerous character." 

Another American, Dr. Birchmore, speaks of 
scopolamin-morphin as the " ideal anesthetic," an 
anesthetic which is " without risk to either mother 
or child." 

Dr. Williams of Johns Hopkins says he has em- 
ployed scopolamin-morphin in two separate series 
of cases without satisfactory results, nor did they in 
any way approach the claims made for the method. 

Dr. Williams does not state the dose employed. 



312 THE TRUTH ABOUT TWILIGHT SLEEP 

If he did not get the results " claimed for the 
method," it argues that he did not obey the rules 
of that method. However, as Dr. Williams says 
he expects to do more with scopolamin-morphin 
next year, it shows at least that he is open-minded, 
and hopes to profit by former mistakes — for such 
open-mindedness we mothers should be grateful and 
full of admiration. 

Dr. Hirst of the University of Pennsylvania says : 

"My experience coincided with that of my col- 
leagues in this and other parts of the world. If 
enough morphia is given to abolish pain there is too 
much danger of hemorrhage in the mother and as- 
phyxia in the child. The scopolamin does not 
diminish pain but quiets restlessness." 

Let us take up his objection backwards : 

" Scopolamin does not diminish pain, but simply 
quiets restlessness." 

Dr. Hirst completely ignores the fact that the 
combination of scopolamin with morphin forms a 
practically new drug. 

To quote Gauss: 

"As a matter of fact, recent laboratory re- 
searches have made it appear that in scopolamin- 
morphin we have not, as was formerly believed, two 
independent substances acting in conjunction, but a 



AMERICAN PHYSICIANS' POSITION 313 

new combination which acts in a completely differ- 
ent way from its individual components." 

Tichauer says: 

" The peculiarity of this anesthetic consists in the 
fact that each component assists the narcotic action 
of the other, whilst in other respects they are mutu- 
ally antagonistic." 

Preller of Mannheim says : 

" The combined drugs act mainly upon the ner- 
vous system." 

Of the effect of scopolamin, Kronig says: 

" Scopolamin brings about a disturbance of the 
circulation of such a kind that the pain perceived 
by the nerves is not felt by the woman — there is 
a disturbance of association which makes the apper- 
ception of pain impossible." 

Here are some other professional opinions on the 
workings of scopolamin : 

Ernst : 

" Before sleep begins scopolamin produces a 
diminution of the reasoning powers of the brain." 

Dr. Gertrud Slawyk of Strassburg: 

" The effect of scopolamin upon the human brain 
constitutes the drug as a much-used sedative and 
hypnotic chemical." 

According to the investigations of Finck : 

" By scopolamin the cortex of the cerebrum is 



314 THE TRUTH ABOUT TWILIGHT SLEEP 

completely cut off from the reflex columns of the 
spinal cord." 

The alienists agree that scopolamin has a direct 
effect upon the brain. Sohrt and Bumke (alien- 
ists) describe scopolamin as having " the psychical 
effect of decreasing excitability of the brain." It 
is the disorganizing effect of scopolamin upon the 
memory which is the foundation upon which Twi- 
light Sleep is based. 

"If enough morphia is given to abolish pain 
there is much danger of hemorrhage in the 
mother." 

In answer to this statement of Dr. Hirst's it is 
well to remember that Gauss's average blood loss 
in his first five hundred cases was only 382 grams. 
In the statistics of his first one thousand cases it is 
proven that in 92.8 per cent, of the cases the blood 
loss was normal. 

Read on further — Dr. Hirst says : 

" It was interesting to hear " — at the Freiburg 
clinic — " that the morphia was employed in a single 
moderate dose followed by small quantities of sco- 
polamin. Evidently the disadvantages of the treat- 
ment — hemorrhage and asphyxia — had necessi- 
tated this modification." 

Dr. Hirst confesses in this remark that he knows 
absolutely nothing of the Gauss Dammerschlaf. 



AMERICAN PHYSICIANS' POSITION 315 

Gauss says in his Carlsrhue address of 191 1 : " In 
the six years of the Dammerschlaf there has been 
no change in the technic." 

Only in Gauss's very first experiments was too 
much morphin ever employed — the dose then 
being .015 g. for first injection and .005 g. for sub- 
sequent ones. This dose was quickly reformed to 
the present single injection of .01 g. morphin, not 
because of hemorrhage, but because Gauss consid- 
ered the morphin responsible for the intoxication 
of a certain per cent, of the children. 

That hemorrhage is not a " disadvantage of the 
treatment " is proven by the following reports of 
European obstetricians. 

Frigyesi : 

" No serious cases of atonic hemorrhage." 

Mayer : 

" No atonic hemorrhage." 

Buist of Dundee: 

" Evidence of atonic bleeding is not decisive." 

Kronig : 

" Loss of blood after birth does not exceed physi- 
ological quantity." 

Cremer : 

" Atonic hemorrhage and other accessory effects 
cannot, without further definite proof, be laid at the 
door of scopolamin-morphin." 



316 THE TRUTH ABOUT TWILIGHT SLEEP 

Ziffer: 

" No increase of blood worth mentioning." 

Weingarten : 

" No severe hemorrhage in the period of after- 
birth was observed." 

Even in Hocheisen's dreadful series of misman- 
aged cases he only had five cases of atonic hemor- 
rhage ! 

And here is an American who changed his first 
opinion on this matter : 

Dr. F. S. Newell said at the American Gyneco- 
logical Society, 1906: 

" Scopolamin-morphin does not often give trouble 
nor does it interfere with labor, but a tendency to 
relaxation of uterus and hemorrhage is a danger." 

In a report on further experiments in 1907 with 
123 cases he says: 

" No hemorrhages. Rarely any relaxation of 
uterus." 

As for Dr. Hirst's statement, " my experience 
coincided with that of my colleagues in this and 
other parts of the world," a study of my reports 
from " other parts of the world " prove that Dr. 
Hirst and his American colleagues hold a very iso- 
lated and lonely position on this question of Twi- 
light Sleep. 

The almost theatrical conclusion reached by Dr. 



AMERICAN PHYSICIANS' POSITION 317 

Hirst is really the most original one which has been 
arrived at by any obstetrician. 

Here it is : 

" My conclusion, from this observation and from 
my own experience, was that the quantity of the 
two drugs being insufficient to abolish pain, the 
results secured in this clinic were partly psychologi- 
cal — that is, the patients were assured beforehand 
that there would be no suffering, were delivered in 
a quiet room, were given one moderate dose of 
morphia and became temporarily under its effect 
and being told afterward that they had had no pain 
probably left the institution impressed with that 
belief." 

So Dr. Hirst concludes that the Twilight Sleep is 
entirely a manifestation of Christian Science or 
New Thought, and that all the European obstetri- 
cians are entirely deluded in placing it in the realm 
of scientific obstetrics. If we must believe Dr. 
Hirst and conclude all European obstetricians, sur- 
geons, and alienists to be entirely wrong in attrib- 
uting narcotizing qualities to this combination of 
scopolamin and morphin, can we then believe that 
Kronig and Gauss have been able by mere mental 
suggestion to fool over 5,000 women into believing 
that they were entirely oblivious of the entire proc- 
ess of birth? Is it credible that these women, after 



3 i8 THE TRUTH ABOUT TWILIGHT SLEEP 

being " temporarily under the effect " of the very 
small injection of .01 g. morphin, on " being told 
afterward that they had had no pain left the insti- 
tution impressed with that belief " ? 

Really — as Dr. Kronig says — it shows " the 
desperate corner into which the opponents are 
driven.' , 

Dr. De Lee of the Northwestern University 
spent the extended period of four weeks " person- 
ally observing and critically studying about ten cases 
of childbirth conducted in Professor Kronig' s own 
clinic. ,, 

After this profound and prolonged critical study, 
Dr. De Lee is able to dispose in a few words of a 
method which Drs. Kronig and Gauss have studied 
for over nine years. 

" The impressions received and opinions formed 
were decidedly unfavorable to the method of Twi- 
light Sleep. 

" In all ten cases pains were prolonged." 

Here are the opinions of European doctors on 
this side of the question : 

Brodski of Moscow (200 births) : 

"The narcosis has no unfavorable effect upon 
duration of birth." 

Bass of the Chrobek Clinic of Vienna (107 
births) : 



AMERICAN PHYSICIANS' POSITION 319 

" The pains were never slackened. Scopolamin- 
morphin never caused the slightest retardation of 
birth." 

Laurendean : 

" No unfavorable influence on the birth pains." 

Ziffer: 

" Retardation of birth was only observed five 
times but this was never due to injections. In gen- 
eral, a regulating action on the birth pains was ob- 
served." 

Mayer of Marburg : 

" Out of fifty cases only in two instances were 
the labor pains less, and even in these cases it cannot 
be said that scopolamin was to blame. Diminution 
of the labor pains by scopolamin-morphin has never 
been conclusively proved." 

Constance E. Long of London : 

" Protraction of birth beyond the average dura- 
tion was not observed." 

Weingarten of Giessen : 

" A reduction in the strength of labor did not 
occur in any case. On the contrary, the pains were 
only influenced favorably. In some cases the inter- 
vals were shorter and in other cases violent pains 
occurring at too short intervals were made nor- 
mal." 

Preller of Mannheim : 



320 THE TRUTH ABOUT TWILIGHT SLEEP 

" The duration of birth was not appreciably in- 
creased." 

Frigyesi of Budapest: 

" On the whole no lengthening of the total time 
of birth was noticeable. " 

Wartapetian of Jena: 

" The intensity and frequency of the pains was 
very little affected." 

Lehmann of Carlsrhue, though employing much 
larger doses than those of Gauss, says : 

" There is no appreciable deleterious influence 
upon the course of birth." 

Tichauer : 

" From the results of all statistics we are cer- 
tainly entitled to say that at the worst the birth is 
only retarded to a quite inappreciable extent." 

Von Steinbuchel: 

" No weakening of labor." 

Puschnig : 

" The labor is regulated ; the cooperation of 
mother and the period of afterbirth are normal." 

Pisarewski : 

" The labor and birth process are accelerated." 

Tichauer says of Dietschy, Fabre, and Bourrett: 

" Where effect on labor pains and length of birth 
are concerned, their results correspond with those 
of Gauss." 



AMERICAN PHYSICIANS' POSITION 321 

Matwjejew : 

" I observed acceleration of the birth process." 

Beruti of Buenos Aires (600 births) : 

" No essential influence upon process of physio- 
logical birth." 

As far back as Gauss's first report, the duration 
of his Twilight Sleep births only averaged sixteen 
hours and eleven minutes. 

Even in Hocheisen's 100 mismanaged cases, in 
64 instances the birth pangs were not unfavorably 
influenced, and in some cases even increased in 
regularity and strength. 

Kronig says : 

" If the drug is administered in the proper doses 
no unfavorable influences upon the course of birth 
can be proved." 

To quote Dr. De Lee again : 

" In hwe of the cases instruments had to be used. 
In my opinion two of these were directly rendered 
necessary by the paralyzing effects of the drugs sco- 
polamin and morphin." 

In Gauss's statistics dealing with his first 1,000 
births, the total per cent, of forceps was 7.32, while 
the per cent, of forceps in the last 500 of these cases 
was only 4.95. 

To quote Gauss : 

" In 163 private scopolamin births, not included 



322 THE TRUTH ABOUT TWILIGHT SLEEP 

in my 1,000 clinical cases, I did not use the forceps 
in a single instance." 

In 191 1 in his Carlsrhue address Gauss says: 
" The frequency of forceps at the Freiburg Frauen- 
klinik has settled down to an average of 6-7 per 
cent." 

Dr. De Lee says : 

" Extensive lacerations resulted." 

The fact that almost every mother delivered at 
the Frauenklinik is able to get up the first day after 
birth proves it untrue that mothers are frequently 
lacerated. It is interesting to here recall all that 
Dr. Birchmore (also an American) has said on the 
subject of rupture of the perineum and how espe- 
cially he pointed out the reasons why there is less 
danger of lacerations when scopolamin-morphin is 
employed. (See Chapter IX.) 

Dr. De Lee's assertion that several women became 
delirious and so unruly that ether had to be admin- 
istered — one having convulsions for days — is in 
such contradiction to all that Kronig, Gauss, and 
Siegel have reported that it seems unnecessary to 
add more conclusive testimony. Dr. Siegel's low 
per cent, of rupture of the perineum — 7.5 per cent. 
— proves the great quietude of the patients under 
Dammerschlaf. 

Dr. De Lee furthermore says : 



AMERICAN PHYSICIANS' POSITION 323 

" All these occurrences confirmed my own ex- 
perience with the drug." What frightful mistakes 
in technic and dosage there must have been if Dr. 
De Lee's patients always suffered from weakened 
labor, forceps, lacerations, delirium, and convul- 
sions. 

He goes on to say of his experience with scopola- 
min-morphin : 

" I had used them when first proposed twelve 
years ago. At that time they were extensively em- 
ployed in Europe and America, but were soon dis- 
continued because they were found unpractical and 
dangerous." 

Von Steinbuchel made the first experiment with 
scopolamin-morphin in childbirth in 1903 — only 
eleven years ago. Up to that time this combination 
had only been employed by Schneiderlin and Korfr" 
in surgery. 

The next obstetrical experiments following von 
Steinbuchel's publication of his results were those 
made by Wartapetian at the Woman Hospital at 
Jena. Next followed the experiments of Wein- 
garten at Giessen. These were absolutely the only 
early obstetrical experiments with scopolamin-mor- 
phin. 

So we see that " twelve years ago " no use of sco- 
polamin-morphin in childbirth had ever been made. 



324 THE TRUTH ABOUT TWILIGHT SLEEP 

Dr. De Lee's claim that these drugs were at that 
time — 1902 — "extensively employed in Europe 
and America " is entirely unsupported by all medi- 
cal literature. 

As for the use of scopolamin-morphin being 
" soon discontinued because they were found un- 
practical and dangerous," I need only refer you to 
the reports contained in this book which show to 
what extent experiments are still being continued 
throughout Europe and Great Britain with ever- 
increasing good results. 

" I visited the famous maternities of Berlin, 
Vienna, Munich, and Heidelberg and in all of them 1 
upon inquiry I was told that that method had been 
tried and discarded." 

If the method has been abandoned at the Berlin 
Charite we of course know why — because of 
Hocheisen's failure and Bumm's opposition; but 
what about the Berliner Klinic and Dr. Bruno 
Bosse's great success with Twilight Sleep? 

In Vienna, Twilight Sleep is employed at the 
Chrobek Clinic, the early experiments there being 
first reported upon by Dr. Oscar Bass. 

Should any mother in Munich desire painless 
childbirth she may obtain it by applying to Dr. 
Doderlein, or his assistant, Dr. A. Zinsmeister, at 
the Munich Frauenklinik. They report in 19 13 



AMERICAN PHYSICIANS' POSITION 325 

that this " semi-narcosis is a great blessing to the 
mothers." 

As for Heidelberg, I have no records from this 
city, so I cannot refute Dr. De Lee's statement that 
the method has there been tried and discarded. 
However, Lehmann of Carlsrhue and Kronig and 
Gauss of Freiburg are to be reached by only a few 
hours' travel from Heidelberg, so Twilight Sleep is 
fortunately within the reach of all Heidelberg 
mothers. 

Now I want to say a few words in regard to the 
" investigations " which were made by visiting 
physicians — including the Americans — in Frei- 
burg. 

Unfortunately, both for Kronig and Gauss as 
well as the visiting doctors, it is only possible that 
medical visitors be permitted to witness the births 
in the fourth-class free wards. The German phys- 
icians of this ward are in the earliest process of 
training; they must, in fact, remain here for six 
years before proceeding to higher wards. The 
fourth-class midwives are also in their initial stage 
of training. Naturally the cases of these men and 
these nurses are by no means representative, and 
Twilight Sleep as here conducted is a very different 
matter from the Twilight Sleep of Kronig and 



326 THE TRUTH ABOUT TWILIGHT SLEEP 

Gauss in the first-class ward. It is just the differ- 
ence that is to be expected in any work that is being 
done on the one side by amateurs and on the other 
hand by experts. 

To show you the difference in the results obtained 
in the different wards and how much separate 
rooms, exterior conditions, and the personal science 
of the doctors has to do with successful Dammer- 
schlaf, I want to give you the following statistics 
of a series of 600 births occurring in the four wards 
of the Frauenklinik. 

In the first-class ward (where the patients are in 
separate rooms and there is no examination by stu- 
dents), amnesia was obtained in 81.81 per cent. 

In the second-class (where there are a number 
of patients at the same time but no examination 
by students), amnesia was obtained in 70.5 per 
cent. 

In the third-class (where there are a larger num- 
ber of patients together and examination by stu- 
dents), amnesia in 61.10 per cent. 

In fourth-class free ward (for the training of 
midwives and students), amnesia was obtained in 

60.79 P er cent - 

Furthermore, in the yet unpublished record made 
by Dr. Kurt Hell wig of the Frauenklinik on 600 
births extending from August, 191 1, to December, 



AMERICAN PHYSICIANS' POSITION 327 

191 2 (when there had been 3,600 Dammerschlaf 
births at the Frauenklinik), Dr. Hellwig draws 
especial attention to the contrast of the figures of 
successful Dammerschlaf in the first- and second- 
class wards from those of the third- and fourth- 
class : First-class, 73.3 per cent. ; second-class, 
70.4 per cent; in the third-class, 51.6 per cent.; 
fourth-class, 53.2 per cent. 

Moreover, during the past year, as you have read, 
the new simplified method of Dr. Siegel was being 
tried out in the fourth-class ward of the Frauen- 
klinik. 

The visiting physicians, after witnessing a few of 
these wholly unrepresentative births, arrive at posi- 
tive conclusions on the merits or demerits of the 
method of Twilight Sleep. When, as is the case of 
a body of visiting physicians, Kronig or Gauss make 
addresses to the physicians, these addresses are de- 
livered in German and are therefore of little assist- 
ance to doctors who do not understand that lan- 
guage. 

When Professor Kronig and Dr. Gauss were 
planning to deliver addresses at the foreign meet- 
ings of medical associations (such as Gauss at Chi- 
cago and Kronig at Sheffield), they prepared their 
papers in German and these were then translated 
into English by Mr. Hill of the Berlitz School in 



328 THE TRUTH ABOUT TWILIGHT SLEEP 

Freiburg. The papers were then carefully studied 
and their English mastered. 

With only a limited knowledge of English, when 
either Kronig or Gauss attempt to make extempore 
speeches in our language, the result is picturesque 
but not exactly classic. 

(Here is an example of Dr. Gauss's piquant Eng- 
lish : Speaking of his handwriting, which is rather 
bold, he said, " My pen she is large.") 

There are no published translations in English of 
Gauss's papers on the subject, and doctors come to 
Freiburg and go away in ignorance of all that he 
has written upon Twilight Sleep. To one Ameri- 
can doctor I loaned my translations, and this doctor 
afterward told me if the American doctors could 
only get English translations of Gauss, they would 
in a few hours be much better able to grasp the idea 
of the method than they were after witnessing a lim- 
ited number of births in the fourth-class ward. 

We will now consider the charge brought against 
Kronig and Gauss by the American medical jour- 
nals, of " instigating or endorsing such sensational 
puffs for themselves " — this refers to the publicity 
which has been given the method of Twilight Sleep 
by other writers and myself in American magazines. 

Kronig and Gauss do not need or desire exploi- 
tation; in fact they made it as difficult as possible 



AMERICAN PHYSICIANS' POSITION 329 

for a journalist to obtain information at the Frauen- 
klinik; but they could not close the mouths of grate- 
ful mothers who had there had their children under 
Twilight Sleep; they could not prevent one from ob- 
taining and translating Gauss's writings on the sub- 
ject; they could not close the University Library 
with its volumes of medical magazines containing 
the records of the past eleven years' experimentation 
with scopolamin-morphin on the Continent; they 
could not prevent a sincere student from collecting 
data from the rest of the medical world wherever 
Twilight Sleep has been tried. 

The Frauenklinik is not run for money; it is a 
State institution and is endowed by the Grand Duke 
of Baden. It is a small hospital and can only ac- 
commodate a limited number of first-class patients, 
therefore American mothers were not particularly 
welcomed, but they could not with humanity be 
turned away after they had come from such a dis- 
tance to beg for painless delivery. 

The American mother, however, who occupied a 
first-class room in the Frauenklinik at an absurdly 
low cost could not escape the unpleasant realization 
that she was practically accepting the hospitality of 
the Grand Duke of Baden, for she was occupying a 
room and being benefited by terms planned for the 
subjects of the Grand Duke only. 



330 THE TRUTH ABOUT TWILIGHT SLEEP 

Drs. Kronig and Gauss — absorbed as they were 
the past year, in their investigations of radium — 
did not by any means enjoy the vast number of visit- 
ing physicians from abroad who, awakening at last 
to the wonders of Twilight Sleep, came and begged 
to be shown. One of the doctors of the Frauen- 
klinik naively complained : " It makes me so nerv- 
ous to have eleven strange doctors watching me." 

Kronig and Gauss did not want to be interrupted 
and bothered, and as Dr. Kronig said to one Ameri- 
can doctor who was criticizing the method : " Why 
do you come here? We don't ask you to — we 
don't want you." 

The doctor replied : " What choice have we ? 
We must find out about this thing and to do so we 
have to come to the fountain-head." 

It is absolutely unfair to the entire staff of the 
Frauenklinik to insinuate, as the Journal of Ameri- 
can Medical Association of Chicago has done, that 
these doctors have shown " an advertising initiative 
which bids fair to rival Friedmann." 

For the advertisement which Twilight Sleep has 
had we must blame the thankful mothers — if blame 
there be — who desire that their sister-mothers may 
know the wonders of this method. These mothers 
feel that the opposition of the American physicians 
is unfair and prejudiced, and furthermore in some 



AMERICAN PHYSICIANS' POSITION 331 

cases unreliable because based on snapshot views of 
the Dammerschlaf. 

There is something curiously sardonic in the fol- 
lowing fact: After the most bitter opposition to 
the Freiburg method had come from the American 
medical profession, Twilight Sleep to-day in the 
Freiburg Frauenklinik is almost dependent for its 
continuance upon one American physician. 

This doctor came to Freiburg with other Ameri- 
cans to study the Dammerschlaf and he was there 
when war was declared. 

Dr. Kronig had to leave immediately to take 
charge of a large hospital for the wounded near the 
fighting line in Alsace-Lorraine, outside of Carls- 
rhue ; Dr. Schneider had gone to the front at the out- 
break of war; Dr. Gauss went with the forces as 
surgeon and reserve for the aeroplane service, and 
all the other German doctors, except one, were with 
the army, so the poor Frauenklinik was almost de- 
pleted. 

The Headnurse (Oberin) to whose devoted co- 
operation Kronig and Gauss owe so much of their 
successful development of Twilight Sleep, is a num- 
ber of the Red Cross Baden Frauenverein ; all her 
desires naturally led her to want to join the army at 
the front, but she soon saw she would be far more 
needed at the Frauenklinik by the mothers who, war 



332 THE TRUTH ABOUT TWILIGHT SLEEP 

or no war, must continue to bring children into the 
world, so, unselfishly putting aside her own im- 
pulses, she remained in Freiburg at her post. 

The Headnurse appealed to this visiting American 
doctor to stay and assist her in conducting the cases 
of Twilight Sleep; he promised to remain if possible 
throughout the war. So we have the singular 
anomaly of an American providing painless child- 
birth for the German mothers! It seems after all 
but the just payment of a debt which America owed 
Freiburg for the relief which the Frauenklinik had 
brought American mothers. 

AN AMERICAN DOCTOR WHO WAS CONVERTED TO 
TWILIGHT SLEEP 

Here is the experience of W. H. Wellington 
Knipe, A.M., M.D., Adjunct Professor of Obstet- 
rics, New York Post Graduate Medical School and 
Hospital ; Attending Obstetrician, Gouverneur Hos- 
pital. 

Dr. Knipe spent a fortnight in Freiburg in July. 
He came there with almost as much prejudice against 
the method as has been shown by the other Ameri- 
can doctors whose opinions are quoted in the begin- 
ning of this chapter; now hear, in his own words, 
how Dr. Knipe changed his opinion : 



AMERICAN PHYSICIANS' POSITION 333 

" Having used scopolamin-morphin in my hospital 
v/ork several years ago and having discarded the 
method as dangerous, I entered Freiburg a skeptic ; 
and it was only after repeated demonstrations of 
successful Twilight Sleep that at last I became a con- 
vert and I was forced to admit the poor results that 
we had obtained previously with scopolamin-mor- 
phin were due to the fact that we did not follow the 
Freiburg rules." l 

Dr. Knipe has here voiced the truth about the at- 
titude of all the American doctors who have dis- 
carded and then opposed the method; he further- 
more honestly confesses that the American failures 
were " due to the fact that we did not follow the 
Freiburg rules." 

Dr. Knipe's next sentence is important both as a 
prophecy and an acknowledgment of the importance 
of Twilight Sleep. 

" Inasmuch as the Freiburg treatment is bound 
to become the method of the future, it will become 
necessary for the hospital to have proper accommo- 
dations for these cases." 

The title of Dr. Knipe's paper is " Twilight Sleep 
from the Hospital Viewpoint." 

1 From The Modem Hospital, Vol. Ill, No. 4, Oct. 1914. 
Published in St. Louis. Pages 250-251. 



334 THE TRUTH ABOUT TWILIGHT SLEEP 

He continues : 

" The one requisite for the proper induction of 
Twilight Sleep is quiet. 

" The proper location of the delivery-room is an 
inside court where the least possible noise obtains." 

In Freiburg, the ward delivery-room opens on to 
the court-yard in which there are trees and flowers ; 
the only sounds which disturb the quiet of the court 
are the songs of birds and the occasional rubber- 
tired entrance of a motor car. 

Often times the groups of women in this court 
suggest a scene lifted bodily from light opera — 
which may seem an incongruous simile, considering 
the portent of these women's presence at the Frauen- 
klinik — these mothers are frequently peasants from 
the Black Forest who are arrayed in full skirts, 
and be-ribboned, picturesque head-gear — costumes 
which we foreigners only see upon the stage when 
at home. 

Here the mothers-to-be sit in serene patience in 
the sunlight and shade, awaiting their hour of de- 
livery — serene and unafraid — for they realize that 
in Twilight Sleep they will be mercifully oblivious 
of the trial of childbirth. 

To resume the quotations from Dr. Knipe : 

" All care should be exercised that the noise from 
the rest of the hospital should not reach the Twi- 



AMERICAN PHYSICIANS' POSITION 335 

light room. This quiet may be procured by double 
doors, padded doors, rubber matting, etc. In the 
private operating room, where only one patient is at 
a time, it will be relatively easy to obtain the desired 
quiet, but in the ward operating-room where there 
may be two or three patients at one time — which 
of course is unavoidable in a large service — one 
patient may disturb another to some degree. 

" Besides quiet, means must be used to obtain 
darkness. It is not necessary that this should be in- 
tense, but all care should be used to prevent the en- 
trance of bright light. 

" During the inducing of Twilight Sleep the pa- 
tient is kept in the delivery-room and in bed and in- 
asmuch as the process consumes generally several 
hours it is impossible to keep the patient on the hard 
operating table all this while. At Freiburg the de- 
livery-room contains three beds and it is in these beds 
that the women are delivered, the operating table 
being only used for those cases requiring operative 
interference such as forceps, version " (turning of 
the child), "etc. Each bed is screened from its 
neighbor by curtains of muslin and the rest of the 
delivery-room is like an ordinary operating room 
with the regulation aseptic furniture, sterile recep- 
tacles, instruments, trays, etc." 

I remember observing once that the only unsani- 



336 THE TRUTH ABOUT TWILIGHT SLEEP 

tary, unwashable thing in the room was a calendar. 

Dr. Knipe lays great stress on the importance of 
the proper nursing in Twilight Sleep. 

The nurses at the Freiburg Frauenklinik are fre- 
quently Black Forest peasants who are physically 
strong and mentally intelligent, responding easily to 
training. Dr. Knipe says these nurses must have 
had at least four months' experience as assistants in 
the delivery-room before being placed in charge of a 
case. The nurse examines the heart of the unborn 
child every fifteen minutes, tests the patient's various 
reflexes, and gives the injections accordingly, sub- 
ject to the instructions of the attending doctor who 
comes regularly every hour to examine the Twilight 
Sleep patient. These nurses become peculiarly ex- 
pert and, as Dr. Knipe says, " it will become neces- 
sary for us in America to take especially intelligent 
nurses who are interested in this work and train 
them in this particular method," if we are to have a 
similar success to that attained in Freiburg. 

Dr. Knipe speaks of the Straub Scopolia Haltbar 
(invariable scopolamin), which is made by the addi- 
tion of " the sexatonic alcohol mannite to the scopo- 
lamin solution ; " he is, however, mistaken in his 
statement that this preparation is " manufactured 
by one of the German drug firms"; Hoffman La 
Roche's factory is situated in Switzerland and since 



AMERICAN PHYSICIANS' POSITION 337 

the war began the firm have issued a statement de- 
claring they are not German. 

Dr. Knipe says, " There seems to be no reason 
why the chemist should not make up a stable solu- 
tion for hospital use by the addition of mannite so 
that i cc. of the solution equals .0003 g. scopolamin." 

The bed exercises of which I have written in a 
former chapter, from what I have seen in the first- 
class ward, are described by Dr. Knipe as follows : 

" Within twenty-four hours after the birth of the 
child at Freiburg passive exercises are instituted of 
the upper extremity, abdomen and back and lower 
extremities and perineum of the patient, and it will 
become necessary in hospital work to instruct the 
nurses in the method of giving these exercises." 

In addition to describing one of the exercises 
which I have already given, Dr. Knipe gives another 
which is new : 

" Separating the knees with the patient resisting 
and in approximating'' (bringing together again) 
" the knees against the patient's resistance. The pa- 
tients take kindly to these exercises and claim they 
feel very much better after them. . . ." 

After the exercises have been continued night and 
morning, he says, " it is surprising with what rapid- 
ity the uterus involutes " (shrinks back to the nor- 
mal). 



338 THE TRUTH ABOUT TWILIGHT SLEEP 

"If the patient is running a temperature or if 
there has been a bad laceration of the perineum, the 
patient is kept in bed for a longer period and the ex- 
ercises are not taken." 

Dr. Knipe then writes of the necessity of keeping 
a chart of accurate notes on the conduct of the birth 
such as is kept at the Frauenklinik ( I have given this 
chart in Chapter V), and he says that " it is only by 
keeping strict record of these conditions," — amount 
of injections, character of pains, voluntary muscular 
efforts of the patient, after-birth hemorrhage, the 
condition of the newborn, etc. — " that one is able to 
judge of the value of the method." 



XVIII 
The British Success With Twilight Sleep 

THE most striking feature of the British re- 
ports on scopolamin-morphin is the perfectly 
fair, unprejudiced, open-minded attitude of the 
British doctor. 

As you now know, from Chapter III, Twilight 
Sleep is no longer a mere experiment in Britain ; it is 
the same settled institution that it is in Germany and 
many other foreign countries. 

There is no doubt that within a few years every 
doctor in Great Britain will employ scopolamin-mor- 
phin in birth just as he now employs chloroform in 
operations. 

From my personal inquiry of the British doctors, 
I find the majority of them employ the scopolamin 
made by Burroughs Wellcome : Sir Halliday Croom 
and Dr. Constance Long both spoke particularly of 
the great purity and dependability of the Burroughs 
Wellcome drugs. 

While these reports given in this chapter naturally 
deal with the early experiments of the British doc- 

339 



340 THE TRUTH ABOUT TWILIGHT SLEEP 

tors with Twilight Sleep, I am able to assure you 
that all the doctors — except Dr. Corbett, who is no 
longer attending maternity cases — whose reports 
I here give, are to-day firm adherents of the method, 
and, as Sir Halliday Croom said : " It is now such 
an everyday affair to administer scopolamin-mor- 
phin to our patients we no longer think of keeping 
records of these births." 

SIR JOHN HALLIDAY CROOM X 

Sir Halliday Croom's report, made in 1908, deals 
with his first sixty-two cases. 

He began his experiments with the small dose of 
%oo of a grain of scopolamin with Vq of a grain of 
morphin with uneven results, but a diminishing of 
the painfulness of the uterine contractions although 
consciousness was in no way abrogated. 

" Strangely enough," writes Sir Halliday Croom, 
" with this dose the patients all complained of exces- 
sive thirst. The effect upon the child was absolutely 
nil." 

He eventually increased the dose to %oo of a grain 
of scopolamin to % of a grain of morphin, and found 
the results much more satisfactory. 

1 " A Short Experience of Scopolamin-morphia Narcosis in 
Labor," by Sir. J. Halliday Croom, M.D., F.R.C., S.E. Pro- 
fessor of Midwifery, University of Edinburgh. Obstetrical 
Transactions, Edinburgh, Vol. XXXIV, pages 1908-09. 



BRITISH SUCCESS WITH IT 341 

" The painfulness of the contractions was in some 
cases entirely abolished. The patients slept soundly 
in the intervals between the pains, and in most cases 
for one or two hours after the completion of labor. 
It is to be noted that with the larger dose of either 
/4oo or %oo of a grain there was never any complaint 
of thirst such as was so striking with the smaller 
dose of %oo of a grain of scopolamin. 

" Seventy per cent, of the children in these cases 
were born vigorous, 27 per cent, required slight re- 
viving, and 3 per cent, required thorough resuscita- 
tion. No children were lost. 

" In 37 cases one injection of the drugs was suf- 
ficient to obtain the desired effect. In the other 25 
cases, one or other or both drugs were repeated in 
doses varying in the case of scopolamin from %oo 
to Koo of a grain." 

Sir Halliday Croom found that the repetition of 
the scopolamin prolonged and slightly deepened the 
effects upon the mother and child, but the repetition 
of morphin caused a much more distinct increase in 
the effects, particularly upon the child. " So much 
so was the case that latterly I gave up repeating mor- 
phia entirely." 

Sir Halliday, after going into details of the effect 
of different doses on different groups of cases, con- 
tinues : 



342 THE TRUTH ABOUT TWILIGHT SLEEP 

" I gave the drug mainly in the second stage of 
labor and found that the results were threefold. 

" I. It acted as a soporific. 2 

" 2. It produced narcosis and in some cases even 
complete anesthesia. 

" 3. It appeared to cause amnesia, abolishing re- 
membrance of the suffering during labor. 

" The drug was administered once or twice during 
the second stage, not oftener. The soporific effects 
were very marked as a rule, sleeping between the 
pains and only awakening to a certain limited ex- 
tent during the acme of the pain. The pains them- 
selves were very much modified, the patient com- 
plaining only of discomfort, not actual pain. 

" The sleep after labor lasted for two or three 
hours in most cases." 

In two cases forceps were used and the patients 
delivered artificially without suffering. 

" Perhaps even more striking is the fact that in al- 
most all cases the memory of the pain suffered was 
either very much blurred or altogether abolished. 
In several cases the patients woke up two or three 
hours after the completion of labor without any 
recollection whatever of what had taken place and 
could hardly be persuaded that their labors were 

2 A medicine which produces sleep as distinguished from a 
mere anodyne, which only soothes. 



BRITISH SUCCESS WITH IT 343 

over, until their children were produced in evidence. 
In many cases the whole circumstances attending 
labor were a mere reminiscence, and the patients re- 
membered the pains only in a vague manner as if 
they had occurred far away." 

" Where the drug was administered during the 
first stage of labor it sometimes hastened the dila- 
tion of the cervix " (neck of the womb). 

" I noted no bad results whether to the heart, 
respiration, or pulse, and even in the minority of pa- 
tients, who did not respond at once to the treatment, 
there were no bad results. 

" The only untoward effect, as far as my expe- 
rience goes, is the fact that the child is often born 
sleepy and almost comatose and remains so for some 
time after birth. The child is not actually still- 
born but it breathes only slowly, does not cry, and 
has all the appearance of being under the influence 
of the narcotic element. This has never been a 
serious complication, but one easily dealt with by 
the ordinary methods of revival, and no children's 
lives were sacrificed." 

It is comforting to realize how much the last six 
years have changed Sir Halliday Croom's opinion as 
to the " untoward effect " on the child, for he now 
considers scopolamin-morphin without danger to 
the child and says the child is only born sleepy when 



344 THE TRUTH ABOUT TWILIGHT SLEEP 

there has been faulty dosage of the mother. If the 
child should be born oligopneic, Sir Halliday's 
maxim — as you may remember — is now, " Let 
them alone and they'll come to." 

His many years' experience with Twilight Sleep 
has also altered the following opinion, expressed 
after the first sixty-two cases : 

" No untoward events occurred in the administra- 
tion of the drug so far as the mothers were con- 
cerned except perhaps a possible tendency to post- 
partum hemorrhage. In 3 cases of the 62 that was 
noticeable, though not to any dangerous extent.'' 

These three cases must have been the ones which 
Sir Halliday said had been reported to him by other 
doctors attending the cases of scopolamin-morphin 
patients, for, as you may remember, he said to me 
that personally he had had no experience with a 
tendency in his own patients to after-birth hemor- 
rhages. 

"Of the 62 cases none were totally insusceptible 
to the drug, but it must be admitted that the sus- 
ceptibility of patients varied very considerably. In 
one case the result was just the opposite from what 
was looked for, the patient becoming excited — al- 
most violent — and required the administration of 
chloroform." 

Sir Halliday Croom's long experience with the 



BRITISH SUCCESS WITH IT 345 

drugs has now produced such certainty of technic 
that these uncertain results are no longer experi- 
enced. 

He finds that this method in private practise " en- 
ables one to avoid to a considerable extent the dis- 
tress and anxiety to the relatives caused by the out- 
cries of the sufferer. Moreover, the drug can, with- 
out bad effect, be administered at a considerably 
earlier stage in labor than is the case with chloro- 
form." 

The method does not delay the early stages of 
birth ; " in some cases it even seems to expedite the 
dilatation of the os, as I have already pointed out, 
and it certainly serves to tide the patient in comfort 
over what is to her so often the most tedious and 
trying part of labor. ... As regards its effect on 
the duration of labor, I am not convinced that it in 
any way hastens the process. At the same time I 
do not think that it delays progress, because the 
scopolamin appears to counteract any influence 
which morphia might have in stopping or weaken- 
ing the pains. I am inclined to think that on the 
whole the administration of scopolamin and morphia 
makes very little difference to the duration of 
labor." 

Sir Halliday Croom considers the only counter- 
indications for the use of Twilight Sleep are feeble- 



346 THE TRUTH ABOUT TWILIGHT SLEEP 

ness or irregularity of pains, or where the patients 
are physically weakened. 

The best dose he has found to be %oo of a grain 
scopolamin + % of a grain morphin, administered 
when the pains occur regularly at intervals of a few 
minutes. 

" The scopolamin may require to be repeated in 
the course of one and a half or two hours. As a 
rule, %oo of a grain scopolamin is sufficient as a sec- 
ond dose. 

" But in all cases the dosage — and this particu- 
larly refers to the second dose — must be gaged by 
the patient's state of mind as to wakefulness or ex- 
citement, and by her power of perception and mem- 
ory of what is going on around her." 

Sir Halliday Croom employs scopolamin in the 
tabloid form as prepared by Burroughs Wellcome, 
which is very carefully standardized as to dosage. 

The finale of this most valuable paper on Twilight 
Sleep is: 

" On the whole, I am of the opinion that there 
can be no question that in scopolamin-morphia nar- 
cosis we have an efficient means of controlling the 
pain of labor and one that is practically safe when 
ordinary precautions are taken." 



BRITISH SUCCESS WITH IT 347 



DR. CONSTANCE LONG 

At a meeting held on the 7th of January, 19 13, the 
president of the Association of Registered Medical 
Women, Dr. Constance Long, read a paper on 
" Scopolamin-Morphin in Labor." 3 

She had used these drugs in private practise and 
had not found that labor had been protracted be- 
yond the average time, nor had the infant been in 
any way endangered, in spite of a certain amount of 
cyanosis (a congestion of the venous system so 
that the blue blood of the veins discolors the skin) 
at birth. " The dangers to the child have been over- 
stated by British writers. 

" Scopolamin is a perfectly safe drug for the 
mother, provided its dosage is understood. For the 
safety of the child, the initial dose of %-% of a 
grain of morphin should not be repeated. 

" The effect of the drug in modifying labor pains, 
combined with the amnesia commonly produced, 
might abolish the dread of parturition " (the bring- 
ing forth of children) " and thus induce a rise in the 
birth-rate. 

" The constant attendance of the physicians is not 
essential, provided an intelligent nurse is in charge. 

" The patient should be kept on her side until the 

3 British Medical Journal, Jan.- June, 1913. 



348 THE TRUTH ABOUT TWILIGHT SLEEP 

effects of the drug have passed off and the same pre- 
caution should be observed with regard to the in- 
fant." 

Dr. Long tells me that her first injection is M.00 
of a grain scopolamin to % or % of a grain mor- 
phin; the second injection is again Koo of a grain 
scopolamin alone or otherwise %oo of a grain scopo- 
lamin. 

She employs the memory test, gaging her dosages 
entirely by the apperception of the patient. 

dr. r. c. buist 4 

The following paper was read by Dr. Buist at the 
meeting of the British Medical Association at Shef- 
field in 1908. 

Dr. Kronig, who was present, had just presented 
another paper on " Scopolamin-Morphin Narcosis 
in Labor" immediately before Dr. Buist. I will 
not here reproduce Dr. Kronig' s paper, as it differs 
but little from his publication on the subject which 
I have already given in Chapter X. 

Dr. Buist's address was as follows : 

" Soon after the appearance of Gauss's paper, I 
gave my ward sister instructions that in any cases 

4 "The Use of Hyoscin-morphin Anesthesia in Natural 
Labor," by Robert Cochrane Buist, M.D., CM. Edinburgh. 
British Med. Journal, July-Dec, 1908. Vol. II. 



BRITISH SUCCESS WITH IT 349 

where the labor became distressing the patient 
should have an injection of hyoscin and morphin. 
In the earlier cases I was summoned to each case 
and of the later cases I have seen a large proportion 
at some stage of their progress. 

" The practical conclusion is that I use the method 
freely in private practise, that when I am in charge 
of the maternity wards it is used as a routine 
method, and that the house surgeon uses it when I 
am in charge of the out-patient department. 

" For the best results it requires a little experience 
in dosage, but properly employed it is capable of 
saving the practitioner many a worrying day and 
weary night and the patient much exhausting rest- 
lessness and some operative deliveries." 

Dr. Buist reports on only sixty-five selected cases 
— thirty-one were mothers bearing first children — 
the records of which were made by pupil nurses 
whose task was to observe the uterine contractions. 

" The uterine contractions seemed essentially to 
be unaffected. In case after case their interval 
is the same before and after the injection, and if in 
some cases the patient goes fully to sleep she is 
found to have made progress when she is again ex- 
amined. In many cases the contractions became 
more regular." 

In the hospital Dr. Buist employs .00065 g. ( = 



350 THE TRUTH ABOUT TWILIGHT SLEEP 

Yioo of a grain) scopolamin + .01 g. (= % of a 
grain) morphin, but in private practise he has gen- 
erally found .016 g. (= % of a grain) morphin to 
be the more satisfactory dose. 

Dr. Buist's rule for procedure is : 

" Whenever your patient is distressed by the pains 
and you expect the labor to last more than an hour, 
give an injection of hyoscin and morphin ; if you ex- 
pect it to last a considerable time, return in from 
three to four hours and if necessary repeat the in- 
jection. The second dose may be of morphin alone 
or of hyoscin alone or of both, as you think neces- 
sary, to produce the mental condition you desire. 
If you think from the examination that the contrac- 
tions are really violent, lay stress on the morphin; if 
you think that the patient is reacting excessively to 
what contractions she has, emphasize the hyoscin." 

In addition to Dr. Buist's experiences at this early 
time his house surgeon used the method in thirty 
cases with results parallel to Dr. Buist's. 

The concluding words of this paper are : 

" It is difficult to describe the attractions in pri- 
vate practise of a method which relieves the patient's 
suffering while it allows labor to progress regularly 
and which does not require the constant personal 
presence of the medical practitioner, as the obstetric 
anesthesia with chloroform does." 



BRITISH SUCCESS WITH IT 351 

In Chapter III I have told of Dr. Buist's con- 
tinued and successful employment to-day of Twi- 
light Sleep, both in private practise and the Dundee 
Royal Infirmary. 

DR. DUDLEY C0RBETT 5 

Dr. Corbett makes the following conclusions on 
the value of Twilight Sleep : 

1. "The scopolamin-morphin combination is of 
great value where hysteria and distress are manifest 
during the first stage of labor. If possible, it should 
only be given in the first stage and not repeated. 

2. " No ill effects to the mother need be expected 
even with full and repeated doses. 

3. " No ill effects need be expected for the child 
even where the mother has had full and repeated 
doses, provided the delivery does not take place at 
four hours or less from the time of the last dose, 
otherwise apnea will ensue. On the other hand, 
where the drug is without effect on the mother it is 
not likely to affect the child even if born within the 
four hours. 

4. " The cause of apnea is probably the morphin, 
and so where it is necessary to give the drug late 

6 "The Use of Scopolamin-morphin in Labor," by Dudley 
Corbett, M.A., M.B., B.Ch. Oxon. Late House Physician, 
General Lying-in Hospital, York Road, Lambeth, S. E. Brit- 
ish Med. Journal, April, 191 1. 



352 THE TRUTH ABOUT TWILIGHT SLEEP 

in the first stage or early in the second, the morphin 
should not be given in larger doses than % of a 
grain or omitted. 

5. " A hot bath is the best treatment for the ap- 
nea. 

6. " Strychnin may prove to be a useful addition 
to the mixture. It does not diminish the analgesic 
effect of the combined drugs and it may help to pre- 
vent the apnea of the child." 

Dr. Corbett is now at St. Thomas' Hospital in 
London and as he has forsaken this branch of medi- 
cine he was unable to give me any further informa- 
tion on the subject of scopolamin-morphin. 

DR. ARTHUR INNES 6 

Dr. Innes says: 

" In the majority of cases the baby is born with 
little knowledge on the part of the mother and cer- 
tainly with little remembrance of pain. 

" In several cases the freedom from pain has been 
remarkable. In one case of primipara " (first child) 
" where the os was of the size of a five-shilling piece, 
the baby was born without the knowledge of the 
mother and it was then found that the placenta was 
adherent. After waiting for three-quarters of an 

6 " Hyoscin-morphin Anesthesia in General Practise," by 
Arthur Innes, M.B., B.Ch. The Practitioner, 1912 (1). 



BRITISH SUCCESS WITH IT 353 

hour it was decided to remove the placenta by sepa- 
rating it from the uterine wall. This proved a 
rather difficult matter, but in spite of that, the patient 
required no other anesthetic and her only complaint 
all the time that the manipulations were proceeded 
with was that she was thirsty and would like a cup of 
tea!" 

There were no cases of anything approaching post- 
partum hemorrhage nor did the convalescence seem 
slower. 

Dr. Innes says the pains do come a little slower, 
but that " the lessening of the tension on the nerv- 
ous system of the patient is a great help. 

" It seems to me that in this drug we have a great 
help to the parturient " (child-bearing) " woman 
and that with a minimum of risk to herself or her 
child." 

Dr. Innes' first experiments with Twilight Sleep 
were made in November, 1909. 

DR. J. R. FREELAND AND DR. BETHEL A. H. 
SOLOMONS 7 

I am deeply indebted to Dr. Solomons for so 
kindly sending me the valuable pamphlet written by 
him and Dr. Freeland on Scopolamin-morphin. 

7 " Scopolamin-morphin Anesthesia in Labor," by J. R. 
Freeland, M.D., Univ. Penn. L. M., and Bethel A. H. Solo- 



354 THE TRUTH ABOUT TWILIGHT SLEEP 

This pamphlet deals with one hundred cases of 
primiparse ; they believed that the tests of a compara- 
tively new anesthetic would be more valuable if cases 
of women bearing their first babies were selected, 
because the average duration of labor is longer in 
such cases and the occurrence of abnormalities, such 
as after-birth hemorrhage and adherent afterbirth, 
are less common. 

The reason their record is confined to one hundred 
cases is that they only administered scopolamin- 
morphin when the labor ward was quiet and com- 
paratively empty and therefore stricter attention 
could be paid to both mother and child. 

Drs. Freeland's and Solomons' experiments were 
the direct result of Dr. Kronig's paper read at Shef- 
field in 1908, and they followed as closely as they 
could the Kronig method of administration with the 
exception of the fact that they often administered the 
drugs by mouth instead of by hypodermic injec- 
tions. 

The dosage decided upon after various experi- 
ments was Yi2o of a grain of scopolamin + Ys grain 
morphin. The morphin was not repeated in subse- 
quent injections. 

mons, M.B., Univ. Dublin. L.M., Assistant Masters Rotunda 
Hospital, Dublin. Printed for the authors by John Falconer 
Dublin, also published in British Med. Jour., Jan., 191 1. 



BRITISH SUCCESS WITH IT 355 

Drs. Freeland and Solomons carefully avoided 
producing too deep a narcosis, saying : 

" We consider the purpose of the drug fulfilled if 
the patient sleeps between the pains, waking up with 
more or less demonstration during the height of the 
contraction and again falling to sleep when the pain 
is over." 

This is what Gauss would call an ideal Dam- 
merschlaf. 

Drs. Freeland and Solomons selected patients who 
were particularly noisy and demonstrative in order 
to be able to say definitely how much effect the drug 
had on the sensibility of pain. 

In 10 cases there was complete analgesia, the 
women having no knowledge of pain even when the 
child was born. 

In 57 cases there was a marked effect, sleeping be- 
tween pains and a great decrease of suffering. 

In 20 cases the effect was fairly good as far as 
relieving the pain to a certain extent, though the pa- 
tients did not sleep at all. 

In 13 cases there was no effect, due in four cases 
to vomiting of drug and in 8 to their having received 
too small a dose. 

In some of the cases showing prolongation of 
labor it was due to the fact that the doctors deliber- 



356 THE TRUTH ABOUT TWILIGHT SLEEP 

ately chose " patients least capable of bearing pain 
— in other words those bound in any event to have 
a more or less protracted labor." 

As for the effect on the child, they write: 

" Much has been written about the dangers to the 
fetus " (the unborn child), " but from our cases we 
concluded that this has been exaggerated." 

There was only one child born in a condition of 
apnea and the condition was attributed to morphin. 

Drs. Freeland and Solomons say it is unneces- 
sary continuously to watch the patient. They em- 
ploy the same caution, mentioned by Dr. Long, of 
keeping the patient on her side to prevent the tongue 
falling back during the anesthesia sleep. 

They do not believe in keeping the room dark, as 
they feel it interferes with the nurse's watch for 
complications. 

There were 19 cases of forceps, due in most part 
" to the selection of the cases and the inclusion of 
cases of inertia. " 

There were 2 cases of postpartum hemorrhage, oc- 
curring after the administration of chloroform for 
the use of forceps. 

The conclusions reached by Drs. Freeland and 
Solomons are : 

1. " Scopolamin need not be given in larger doses 
than Yi2o grain. 



BRITISH SUCCESS WITH IT 357 

2. " In the majority of cases it may be given ad- 
vantageously by the mouth. 

3. " It is undesirable to keep patients in a dark- 
ened room whilst under its influence. 

4. " The patient should be carefully watched. 
This can be done equally well by the nurse as by the 
doctors. 

5. " No ill effects to mother or child need be ex- 
pected to follow the rational administration of scopo- 
lamin. 

6. " Whilst its chief indication will be found dur- 
ing the first stage of labor, the fear of rapid delivery 
following its use is not a contraindication." 

Dr. Solomons informs me that he still uses scopo- 
lamin " on the lines set down in this paper." 

The British reports form the strongest combined 
verdict on the merits of Twilight Sleep to be found 
anywhere. 

There is positively no excuse for any woman in 
Great Britain to suffer longer in childbirth when she 
can go to doctors of the highest professional stand- 
ing, and obtain the relief of Twilight Sleep. 



XIX 

Conclusion 

I NOW make my last appeal to every woman who 
has read this book to take up the battle for 
painless childbirth where I have left off. 

I have only been able to provide you the arms 
wherewith to fight, the real battle and its victory lies 
in your hands now. 

Fight not only for yourselves, but fight for your 
sister-mothers, your sex, the cradle of the human 
race. Realize to its fullest the tremendous impor- 
tance of this relief of women in labor, the positive 
necessity of removing the dread of birth-pain from 
the mind of women, a dread which has steadily 
grown until it has developed into a social menace. 

Since it has been known that I am writing a book 
on this subject I have been appalled by the confi- 
dences of women; I have actually been told by un- 
married women that they have remained single be- 
cause of their fear of the tortures of birth; mothers 
of only children have confessed that the terror of a 
repetition of the indelibly-impressed agony which 

358 



CONCLUSION 359 

they suffered in the birth of their first child has pre- 
vented them from ever having a second child ; mar- 
ried women who have had no children have told, 
with the starved eye of cheated motherhood, of the 
cowardice which has made them childless — they 
had heard too much of the agony through which 
other women had passed. 

There are, however, other women to whom 
motherhood is the crowning glory of life, who say 
— and believe they mean it — that to have a child is 
worth going through the tortures of the Inquisition 
itself; but these women are rare and, in their way, 
as abnormal as the woman who avoids marriage 
through a cowardly fear of childbirth. 

The normal human feeling is to abhor pain, to 
want to banish pain from the world for oneself and 
all one's fellow creatures. 

Pain is destructive, disintegrating, inharmonious, 
undermining, unnatural, unnecessary. 

Of course after a woman finds she is to become a 
mother and feels within her the great mysterious 
workings of gestation, the growth in her body of a 
wondrous new life, that little life becomes to her 
far more important than her own; as the months 
pass, verging toward the great climax when the life 
dependent on her shall assume its independence, the 
supernal sense of motherhood effaces all human in- 



360 THE TRUTH ABOUT TWILIGHT SLEEP 

stincts of fear and self-preservation and the mother 
is willing to give her life, if need be, in order that her 
baby may be born safely. No man can ever fully 
realize the truth of this self-effacement of maternity, 
for no man has ever carried within his body the 
burden and the treasure of a child. 

If a man loves a woman deeply he then suffers al- 
most as much mentally, as she suffers physically, 
when the supreme hours of trial arrive. Men have 
written eloquently of man's torture at this time. 

Twilight Sleep therefore concerns the men as 
vitally as it concerns the woman. 

I shall never forget the face of a husband banished 
from his wife's room during her childbirth at the 
Freiburg Frauenklinik ; his face was distorted with 
misery, pallid with terror. It was not the first time 
he had waited and watched through specter-filled 
hours while the woman he loved lay behind a door 
sealed to him, for this was his fourth child. 

The birth of the first had almost cost him his wife, 
the second had been a repetition of the horrors of 
the first, in the birth of the third child the mother 
had been saved but the baby had had to be sacrificed 
and the doctor attending had solemnly warned 
against further children. After some years of in- 
validism it was found that this woman was to be- 
come a mother again. Imagine that husband's state 



CONCLUSION 361 

of mind, for he believed it to be the death knell of 
his wife. Then he heard of Freiburg, of Twilight 
Sleep, of a painless and safe method of childbirth. 
Within three days of having heard of the wonders 
of the scopolamin-morphin method he began the 
journey to Freiburg with his wife. Even Professor 
Kronig and Dr. Gauss felt alarmed when they heard 
the shocking details of the former deliveries. 

When the Twilight Sleep birth of the fourth child 
was over, Dr. Kronig said to the husband : 

" Why were the forceps ever used on your wife? 
— there was certainly no structural reason. I never 
saw a more normal, spontaneous birth." 

One week later this mother attended the christen- 
ing of her boy-baby at the Cathedral ! 

Not long ago a Japanese doctor was discussing 
western medical methods with me, especially the 
wide-spread use of the forceps which he greatly con- 
demned. 

He gave the following adage which they apply in 
Japan to operative interference in birth : 

" When the caterpillar is emerging from the co- 
coon, do not touch; if you interfere, you may not 
only spoil the cocoon but you may kill the caterpil- 
lar." 

The whole future welfare of the child is depend- 
ent on its proper advent into this world and the en- 



362 THE TRUTH ABOUT TWILIGHT SLEEP 

tire after health of the mother lies in the balance dur- 
ing childbirth. 

Many strong, healthy young girls become physical 
wrecks after the calamitous birth of a child. 

It is not the reasonable sequel to romance that 
love should have this culminating agony and shat- 
tered health. 

The kindling of love between a man and a woman 
is a wonderful thing; the mating of those who love 
has a sacred beauty; the merging of two lives into 
the life of a third is the holiest, most exquisite mys- 
tery in the world. The blossoming of this flower 
of the love of a man and a woman should be a con- 
tinuation of the beauty of all that has gone to its 
creation, but is it? No. The culmination of love 
— the birth of the child — is surrounded only by 
thoughts of dread and torture. 

As Dr. Birchmore has said " the pains of mater- 
nity have been a horrid and incontestable truth, but 
now these have vanished and the exhausting ordeal 
of motherhood is gone to be seen no more.' , 

Through Twilight Sleep a new era has dawned for 
woman and through her for the whole human race. 



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INDEX 



INDEX 



Baden, 44, 67. 
Bass, Dr. Oscar, 166, 167. 
Bed exercises, 140, 337. 
Birchmore, Dr., 65, 169, 181, 

362. 
Brodski, Dr. W. A., 18, 230, 

318. 
Buist, Dr. Robt. Cochrane, 53, 

108, 230, 351. 
Bumke, Geheimrath, 124, 127. 

Chlorethl, 279. 
Chloroform, 2, 56, 190. 
Croom, Sir Jno. Halliday, 48, 
59, 339. 

"Dammerschlaf," origin of 

term, 76. 
De Lee, Jos. B., M.D., 306, 

318, 322. 

Frauenklinik, Freiburg, 4, 13, 

153, 201, 249, 329. 
Frederick II, Grand Duke of 

Baden, 36, 38, 39, 186, 

329. 
Freeland & Solomons, Drs., 

354- 
Freiburg, 45, 72, 325. 

Gauss, Dr. Carl J., 4, 32, 46, 
72, 113, 138, 190, 215, 249, 
328. 



Gminder, Dr., 165. 

Goethe, 256. 

Green, Chas. M., M.D., 304. 

Hilda, Grand Duchess of 

Baden, 38. 
Hirst, Barton Cooke, M.D., 

304, 312, 317. 
Hocheisen, Dr., 64, 101, 121, 

163, 303, 226. 
"Hocheisen-Gauss Controver- 
sy," 10 1, 126, 143. 
Holzbach, E., 167, 188, 221. 
Hyoscin, 67, 109. 

Jena Pharmacological Insti- 
tute, 70. 

Kleinertz, F., 191, 230. 
Knipe, W. H. W., M.D, 332. 
Kronig, Dr. Bernhardt, 4, 32, 

-72, 86, 99, 155, 183, 231, 

299. 

Long, Dr. Constance, 58, 60, 
319, 339, 347- 

Mayer, Dr. K., 195, 200. 
"Memory Test," 59, 84, 115, 

161, 172, 260, 271, 287. 
Morphin, 5. 



369 



37° 



INDEX 



Mothers at Freiburg, experi- 
ences of: 
Bissinger, Frau, 39. 
Emmet, Mrs., 26, 
Sargent, Mrs., 29. 
Stamnitz, Frau, 33. 
Steward, Mrs. Cecil, 30. 
Straub, Frau, 20. 



Nicholson, C. M., 71. 

Preller of Mannheim, 109, 
143, 152, 313, 320. 

Salzberger, Dr. Max, 220, 

225, 309. 
Schlimpert, Dr., 93. 
Scopolamin, 67, 80, 92, 149, 

205, 262, 266, 273, 313. 
Scopolamin-morphin, 4, 44, 

63, 70, 148, 162, 186, 203, 

248, 323- 

Siegel, Dr. P. W., 266, 270. 

"Siegel Simplified Method," 
272, 277, 282, 295, 300. 

Simpson, Sir James, Physi- 
cian to Queen Victoria, 
2, 48. 



Steffen, Dresden Royal Frau- 
enklinik, 68, 87, 155, 163, 
203. 

Steinbiichel, von, of Gratz, 4, 

69, 323. 
Straub, Walther, 262. 

Tichauer, Wilhelm, 242, 313, 

320. 
"Twilight Sleep/' 4, 13, 34, 60, 

114, 232, 246, 267, 275, 283, 

294, 30i, 360. 
cost of, 24, 31. 
effects on child, 96, 107, 152, 

221, 238, 255, 292. 
effects on mother, 100, 117, 

159, 193, 226, 256, 290. 
mortality of children in, 

152, 231, 253. 
mortality of mothers in, 

in, 132, 187. 
religious objections to, 2, 

73- 
seclusion of patients in, 
117, 248, 335. 

Victoria, Queen, 2. 

Williams, J. Whitridge, 304, 
3". 



